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POSTOPERATIVE  TREATMENT 


AN  EPITOME  OF  THE  GENERAL  MANAGEMENT  OF  POST- 
OPERATIVE CARE  AND  TREATMENT  OF  SURGICAL  CASES 
AS  PRACTISED  BY  PROMINENT  AMERICAN  AND  EUROPEAN 
SURGEONS.  TOGETHER  WITH  SUGGESTIONS  CONCERNING 
THE  TECHNIQUE  OF  CERTAIN  OPERATIONS  WITH  A 
VIEW    TO    SECURING     BETTER     POSTOPERATIVE     RESULTS 


BY 

NATHAN  CLARK  MORSE,  A.B.,  M.D. 

SURGEON-IN-CHIEF    TO    "EMERGENCY    HOSPITAL,"    ELDORA,    IOWA;    DISTRICT    SURGEON,    CHICAGO    &. 
NORTHWESTERN   AND    IOWA   CENTRAL   RAILWAYS;    EX-PRESIDENT    IOWA   STATE    ASSOCIATION 
OF    R.    R.    SURGEONS;    MEMBER    OF   THE   AMERICAN   MEDICAL   ASSOCIATION,    PAN- 
AMERICAN    MEDICAL   CONGRESS,  INTERNATIONAL   ASSOCIATION 
OF    R.    R.    SURGEONS,    ETC. 


CONTAINING  5  PLATES  AND 
155   OTHER   ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO. 

I0I2    WALNUT    STREET 
1905 


; '  1  6'3 


Copyright,  1905,  by  P.  Blakiston's  Son  &  Co. 


PRESS    OF 

WM.    F.    FELL    COMPANY 

1220-24    SANSOM    STREET 

PHILADELPHIA 


TO 


ELBERT   WARREN   CLARK,  M.D. 

ONE  OF  THE  GRAND  SURGEONS  OF  IOWA 

AS  A  TOKEN  OF  FRIENDSHIP  AND  LONG  ASSOCIATION 

THIS  WORK  IS  RESPECTFULLY  INSCRIBED 

BY  THE  AUTHOR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/postoperativetreOOmors 


PREFACE. 


The  average  graduate  in  surgery  knows  but  little  concerning  tlie 
proper  management  of  postoperative  treatment  of  surgical  cases;  most 
of  his  time  in  college  being  engrossed  with  what  appears  to  be  the  more 
important  matter  of  surgical  technique,  pathology  and  bacteriology. 
He  realizes  the  great  importance  of  minor  details  only  when,  in  actual 
practice,  he  is  thrown  upon  his  own  resources,  and  the  skill  he  may 
then  acquire  is  obtained  through  personal  experiences  with  suffering 
patients.  He  may  visit  the  greatest  clinics  and  witness  the  most 
brilliant  operative  technique,  but  the  curtain  falls  and  his  observation 
ceases  on  the  removal  of  the  patient  from  the  operating   amphitheatre. 

I  have  long  regarded  postoperative  care  and  treatment  as  being 
equal,  if  not  of  greater  importance,  than  mere  brilliant  technic|ue.  Faulty 
technique  may  complicate  or  retard  recovery,  but  faulty  postoperative 
management  has  robbed  many  surgeons  of  what  should  have  been  suc- 
cessful results. 

The  practice  of  asepsis  and  antisepsis  has  removed  many  compli- 
cations which  heretofore  so  commonly  followed  surgical  operations. 
But  from  my  own  experience  and  the  observation  of  cases  occurring  in 
the  practice  of  some  of  our  best  surgeons  I  am  forced  to  conclude  that 
infection  is  often  unavoidable  and  frequently  occurs  under  the  most 
favorable  circumstances.  It  is  these  cases  that  frequently  tax  to  the 
utmost  the  skill  and  ingenuity  of  the  postoperative  attendant. 

Surgeons  differ  radically  over  the  management  of  similar  cases,  each 
basing  his  opinion  on  conclusions  evolved  from  personal  experience, 
hence  the  meagre  information  given  this  important  subject  by  the 
average  modern  text-book  is  frequently  conflicting  and  therefore  a  dis- 
appointment to  the  student  and  busy  surgeon. 

I  have  long  felt  the  need  of  a  work  of  tliis  character,  and  have  at- 
tempted to  compile  a  rational  system,  a  text-book  or  guide  to  the  proper 
postoperative  management  or  treatment,  which,  so  far  as  I  have  been  able 
to  ascertain,  is  the  first  work  devoted  exclusi\-ely  to  this  subject  brought 
before  the  profession. 


VI  PREFACE. 

The  character  of  the  work  admits  of  little  originality.  What  follows 
is,  therefore,  an  epitome  of  the  various  methods  used  or  adopted  by 
modern  American  and  European  surgeons,  much  of  the  information 
being  derived  from  personal  letters,  text-books,  medical  journals,  etc., 
supplemented  when  possible  by  what  my  own  experience  has  led  me  to 
believe  is  rational  and  practical. 

I  have  intentionally  omitted  all  reference  to  surgical  pathology  and 
bacteriology,  confining  myself  as  strictly  as  possible  to  the  subject  under 
consideration. 

Nathan  Clark  Morse. 

Eldora,  Iowa,  October  i,  1905. 


CONTENTS. 


CHAPTER  I. 

PAGE 

PREPARATION  OF  THE  PATIENT  FOR  SURGICAL  OPERATION,...         i-6 

General  remarks;  rationale  of  preparatory  treatment  as  advocated  by  the 
author,  i. — When  complicated  by  phthisis,  Bright's  disease,  jaundice,  dia- 
betes etc.,  2. — Remedies  usually  employed  to  overcome  constipation,  debil- 
ity, anemia,  etc.,  2. — Kelly's  purgative  draft,  2. — Method  of  preparation 
for  laparotomy,  Franklin  H.  Martin,  3. — A.  J.  Ochsner  method,  4;  Joseph 
Price  method,  4;  Sir  Frederick  Treves  method,  6. 

Preparation  of  Field  of  Operation, 7-8 

General  remarks,  7. — For  operation  on  eye,  8;  mouth,  nose,  and  throat,  8. — 
Mayo's  preparation  for  stomach  operations,  8. — Preparation  of  ceni.x  and 
uterus,  9;   bladder,  urethra,  and  kidneys,  9. 

Preparation  of  Field  by  Different  Surgeons, 9-18 

Howard  Kelly's  method,  9. — Joseph  Price  method,  11. — Method  of 
Nicholas  Senn,  11. — Treves'  method,  13. — Keen's  method  for  cerebral 
operation,  14. — Ochsner's  method,  15. — Method  of  Robert  T.  Morris,  15. 
— Final  considerations,  16. — Solutions  to  be  used  in  the  peritoneal  cavity, 
16. — Remarks  on  drainage  by  Joseph  Price,  17. 

CHAPTER  II. 

POSTOPERATIVE  WOUND  SUTURES,  DRAINAGE  AND  DRESSINGS,     19-31 

Postoperative  wound  sutures,  21. — Character  of  sutures,  21. — Double 
ligature  of  arteries,  21. — Method  advocated  by  author  for  closure  of  ab- 
dominal wounds,  21,  22.^Lister's  stitches  of  relaxation  or  button  sutures, 
21. — Irrigation  of  wound  during  operation,  22. — Objections  thereto,  22. — 
Remarks  on  drainage  of  wounds,  29. — Material  for  drainage,  30. — Anti- 
septic gauzes  recommended  by  various  surgeons,  30,  31. — Essentials  requi- 
site for  good  wound  dressing,  30. 

CHAPTER  III. 

POSTOPERATIVE  COMPLICATIONS, 33-69 

Postoperative  temperature  and  treatment,  35. — Diarrhea,  35. — Postopera- 
tive infection,  36;  treatment  of,  38. — Hemorrhage,  39. — Bleeding  from 
bones,  40. — Hemophilia,  40. — Secondary  hemorrhage,  40. — Hemorrhage 
after  nasal  operations,  41. — Hematemesis,  42;  prognosis  and  treatment,  43. 
— Intestinal  paresis,  or  pseudo-ileus,  43;  causes  of,  44;  symptoms  of,  45; 
Wiggin's  method  of  treatment,  46;  use  of  eserin  as  recommended  by  Arndt, 
46. — Postoperative  lung  complications,  47. — Pneumonia,  symptoms,  and 
treatment,  48. — Rochester's  method  of  treatment,  69. — Thrombosis,  49. 
Gangrene,  50. — Cystitis  and  treatment,  51. — Neurasthenia,  52,  53;  nature 
and  severity  of,  54;  diagnosis  and  treatment,  55. — Postoperative  insanity, 
56. — Delirium,  56. — Jaundice,  57.- — Erysipelas,  58;  SA-mptoms  and  treat- 
ment of,  59,  60. — Peritonitis,  61 ;  cause  and  method  of  treatment,  62,  63,  64, 
65;  plan  of  treatment  suggested  by  F.  D.  D wight,  65,  66;  summary  of 
treatment,  66. — Postoperative  bedsores  and  treatment,  67,  68,  69. 

vii 


Vlll  CONTENTS. 

PAGE 

CHAPTER  IV. 

GENERAL  PRINCIPLES  OF  AFTER-TREATMENT  AND  POSTANES- 
THETIC COMPLICATIONS, 71-91 

General  remarks  concerning  care  of  patient  immediately  following  opera- 
tions, 73. — Pallor  and  feebleness  of  pulse  following  anesthesia,  74. — Pos- 
ture of  patient,  74. — Prone  position,  76. — Fowler's  semi-erect  position, 
75. — Lateral  position,  76. — Postoperative  nausea  and  vomiting,  77;  special 
method  of  prevention  and  treatment,  78. 

Postoperative  Surgical  Shock, ." 79-S7 

General  consideration  of  shock,  79. — General  symptoms,  80. — Preventive 
measures,  81. — Surgical  shock  due  to  vasomotor  depression,  nervous  ex- 
haustion, without  serious  hemorrhage,  83. — Treatment,  83. — Shock  from 
toxic  effect  of  the  anesthetic  and  treatment,  85,  86. — Shock  produced  by 
mental  disturbances  and  treatment,  86,  87. — Acute  dilatation  of  the  stom- 
ach, symptoms  and  treatment  of,  88. — Morphin,  indications  for  its  post- 
operative employment,  89,  90,  91. 

CHAPTER  v.. 

TREATMENT  OF  ASEPTIC  AND  SEPTIC  WOUNDS, 93-103 

Postoperative  treatment  of  wounds,  95. — Character  of  dressings,  95. — 
Where  drainage  is  abundant,  96. — Treves'  method  of  wound  treatment, 
97. — Tillman's  paper  dressing,  99. — Pryor's  treatment  of  septic  conditions 
after  plastic  operations,  99. — Principles  which  govern  the  treatment  of 
infected  wounds.  Da  Costa,  Jr.,  100. — Sterilized  olive  oil  in  septic  wounds, 
102. 

CHAPTER  VI. 

ADJUNCTS  OR  AIDS  IN  POSTOPERATIVE  TREATMENT, 105-128 

Hypodermoclysis,  107. — Formula  for  normal  salt  solutions,  107. — Intra- 
venous infections,  109. — Character  and  temperature  of  solutions  for,  109. — 
Rectal  alimentation,  iii. — Philadelphia  General  Hospital  formula  for 
rectal  feeding,  11 1, — Ochsner's  plan  of  rectal  feeding,  114. — Inunctions 
for,  114. — Subcutaneous  feeding.  114. — Bandiging,  principles  of,  and 
various  methods,  114. — Support  and  compress  bandaging,  115. — Method 
of  applying  the  roller  bandage,  116. — Elizabeth  Trotter  abdominal  band- 
age, 121. — Munger's  invalid  bed,  123. — Crosby's  bed,  124. — Sick-bed 
chair,  125. — Hospital  lifter,  124.— Medico-mechanical  apparatus,  127. 

CHAPTER  VII. 

HEALING  OF  GRANULATING  WOUNDS, 129-138 

Kocher's  method,  131. — Harmful  action  of  chemical  irritants,  131.- — Out- 
ten's  method  to  enforce  healing,  131.— Skin  grafting,  133;  Reverdin's 
method,  134;  Thiersch's  method,  134;  preliminary  preparation  of  surface, 
134. — Operation  of  grafting,  135. — Cutting  of  grafts,  135. — Application 
of,  136. — Dressings,  character  of,  and  method  of  applying,  137. — Changing 
first  dressings,  137. — Transplantation  in  mass,  138;  use  of  Cargile  mem- 
brane in,  138. — After-treatment  in  general,  137. 

CHAPTER  VIII. 

OPERATIONS, 139-161 

Postoperative  treatment  of  operations  on  scalp,  141. 

Operations  upon  the  Skull  and  Brain, 141 

General  remarks  on  postoperative  treatment  following  operation  on  the 
skull  and  brain,  141. — Significance  of  sudden  rise  of  temperature  after, 
and  treatment,  141. — Complications  following  operations  on  brain,  142. — 
Postoperative  hernia  cerebri,  143. — Trephining,  143;  closure  of  wound, 
method  of,  143;  after-treatment  of,  144. — Methods  of  preventing  post- 
operative brain  adhesions,  145. 


CONTENTS.  IX 

PAOh 

Operations  upon  the  Jaw, 147 

Superior  maxilla,  excision  of,  147. — Excision  of  lower  jaw,  after-treatment 
of,  method  of  dressing,  feeding,  etc.,  148. 

Excision  of  Tongue, 149 

Whitehead  and  Kocher  methods,  aflcr-trcatmcnt,  149,  151,  152. 

Cleft  Palate,  753 

After-treatment,  Cheyne,  153. — Postoperative  complications,  154. 

Hare-lip, 159 

After-treatment  of,  159. — Lord  Lister's  method  of  dressing  and  after- 
treatment,  159. 

Operations  on  Nose, 159 

Paraffin  injection  for  deformities,  160. 

CHAPTER  IX. 
OPERATIONS  (Continued), 163-184 

Tracheotomy,  Laryngotomy,  After-treatment  of, 165 

Jacobson's  method,  167. — Dietetics,  168. 

Intubation, 169 

O'Dwyer's  method,  169. — Time  for  removal  of  tube,  170. — Feeding  after 
intubation,  171. 

EsoPHAGOTOMY, 171 

After-treatment  of,  171.- — Davis  apparatus  in  after-treatment,  171. 

Operations  on  the  Thyroid  Gland, 172 

Recurrent  hemorrhage  after,  172. 

Mastoid  Abscess, 173 

After-treatment,  173. — Complications  following  operation,  174. 

Empyema  or.  Pleurotomy, 175 

Christie's,  Jr.,  method  or  drainage,  176. — -Senn's  method  of  double  tube 
drainage  and  after-treatment,  176. 

Breast  Amputation, 1 79 

After-treatment  of,  180. — Bodine's  triangular  splint  and  method  of  dressing 
after,  180. — Author's  method  of  dressing,  182. 

CHAPTER  X. 

OPERATION  ON  THE  STOMACH,  LIVER,  AND  INTESTINES, 185-2 11 

General  remarks,  187. — Stomach  drainage.  Mayo,  187.— Gastric  lavage, 
importance  of,  after  operation  on  the  stomach,  Ochsner,  187. — Posture  of 
patient  following  stomach  operations,  188. — Postoperative  treatment  in 
general,  188. — Employment  of  laxatives,  188. — Rectal  feeding  and  method 
of  introduction  of,  189. — Von  Leube's  formula,  89. — Mayet's  pancreatic 
formula,  189. — Rennie's  formula  for  rectal  feeding,  190. 

Cholecystotomy, 191 

General  consideration  of,  191.- — Morrison's  method  of  drainage  of  gall- 
bladder, 193. — Kehr's  method  of  drainage,  194. — Cook's  method  of  drain- 
age, 196. — After-treatment  in  general,  196. 

Abscess  of  the  Liver, 197 

Rhodes'  method  of  procedure  in,  197. — After-treatment,  19S. 

Gastrotomy,  Gastrostomy,  Pylorectomy, 200 

General  remarks,  200. — Feeding  of  patient  and  after-treatment  in  general, 
201. 

Intestinal  Anastomosis, 202 

Use  of  Murphy's  button  and  after-treatment  in  general,  202. 


X  CONTENTS. 

PAGE 

Colostomy, 204 

Methods  of  performing,  204. — After-treatment  in  general,  205. — Treves' 
method  and  after-treatment,  206. — Martin's  method  of  colostomy  for  acute 
obstruction,  208. — Senn  on  intestinal  obstruction,  208. — Postoperative 
enterostomy,  210. 

CHAPTER  XI. 

LAPAROTOMY  AND  OPERATIONS  ON  THE  ABDOMEN, 213-251 

Remarks  on  postoperative  treatment  in  general,  215. — Abdominal  flushing, 
Gruzdeff,  215. — Drainage,  216. — Care  of  bowels,  216. — Urine,  217. — 
Laparotomy  for  septic  conditions,  217. — Position  of  incision,  218. — Lapa- 
rotomy in  peritonitis,  219. — McBurney's  method  in  multiple  abscess,  219. 
—Postoperative  laparotomy  fo  intestinal  adhesions,  220. — Prevention  of 
postoperative  adhesions,  221. 

After-treatment  of  Abdominal  Section, 222 

Method  of  Treves,  222. 

Appendicectomy, 226 

General  principles  governing  postoperative  treatment,  226. — Multiple  ab- 
scess follov^^ing,  227. — After-treatment,  method  of  Ochsner,  229. — Method 
of  Brewer,  229. 

Postoperative  Treatment  of  Ovariotomy,  Howard  Kelly, 231 

Pyosalpinx, 239 

After-treatment  of,  239. — Pelvic  abscess,  method  of  drainage  in,  240. — 
Senn  on  abdominal  drainage  in  general,  242. -^Combined  tubular  and 
capillary  drainage,  244. 

Hernia, 245 

Bassini's  method  of  after-treatment,  245. — Complications  following,  247. — 
Postoperative  hernia,  causes  and  prevention  of,  248. — Umbilical  hernia, 
Mayo's  method  of  after-treatment,  251. 

CHAPTER  XII. 

OPERATIONS  UPON  THE  UTERUS,  VAGINA,  BLADDER,  AND  KID- 
NEYS,  253-275 

Postoperative  treatment,  of  abdominal  hysterectomy,  255. — Vaginal  hyster- 
ectomy, forceps  method,  225;  suture  method,  256. — Alexander's  operation 
for  retroversion,  postoperative  treatment,  258. — Trachelorrhaphy,  after- 
treatment  of,  258. 

Nephrotomy,  Postoperative  Treatment, 259 

Nephrectomy,  postoperative  treatment,  260. — Abscess  of  kidney,  drainage 
of,  261. 

Operations  upon  the  Bladder, 261 

General  remarks,  261. — Suprapubic  cystotomy,  Ochsner's  after-treatment 
of,  262. — Sir  Frederick  Treves'  method  of  after-treatment,  265. — Steven- 
son's suprapubic  drainage-tube,  266. — Permanent  drainage-tube  for,  267. 

LiTHOLAPAXY, 267 

Keegan's  method  of  after-treatment,  267. — Sir  Henry  Thompson's  method 
of  after-treatment,  268. 

Perineal  Lithotomy, 269 

Postoperative  treatment  of,  269. — Complications  following,  271. 

Perineorrhaphy, 271 

Martin's  method  of  after-treatment,  271. — Removal  of  sutures,  274. 


CONTENTS.  XI 

CHAPTER   XJlf. 

PACE 

OPERATIONS  UPON  THE  RECTUM,  PROSTATE  GLAND,  URETHRA, 

AND  SCROTUM, 277-298 

Postoperative  treatment  of  hemorrhoids,  279. — Ligature  method  by 
Allingham,  279. — Clamp  and  cautery  method,  after-treatment  advocated 
by  Pennington,  281. — Secondary  hemorrhage  in,  282. — Abscess  and  fistula 
following,  282. 

Extirpation  of  the  Rectum, 283 

After-treatment  of,  283. — Kraske's  method  of  treatment,  284. — Vaginal 
extirpation  of  rectum.  Murphy's  method,  284. — Postoperative  complica- 
tions, 285. 

Fistula  in  Ano, 286 

After-treatment  of,  286. — Postoperative  treatment,  method  of  Grant,  287. — 
Elastic  ligature  method,  28S. 

Urethrotomy, 288 

General  remarks  on,  288. — Postoperative  extravasation  of  urine  after,  291. 

After-treatment  in  Removal  of  Prostate  Gland, 292 

■  Moynihan's  method  of  after-treatment,  292. — Postoperative  treatment  of 
suprapubic  prostatectomy,  293. — Perineal  prostatectomy,  293. — Postopera- 
tive treatment  in  operation  on  scrotum,  294. 

Castration, 294 

Postoperative  treatment,  294. — Complications  following,  295. 

Hydrocele, 297 

Open  method  of  treatment,  297. 

Circumcision, 29S 

Postoperative  treatment,  Cheyne,  298. — Method  of  after-treatment  ad- 
vocated by  Bransford  Lewis,  298. 

CHAPTER  XIV. 

MISCELLANEOUS  OPERATIONS, 299-329 

Ligation  of  Arteries  and  After-treatment, 301 

Abscess, 301 

General  considerations  of,  301. — Pulmonary  abscess,  Treves'  method  of 
treatment,  303. — After-treatment,  304. 

Bubo, 306 

Krull's  method  of  treatment,  306. 

Gasserian  Ganglion, 307 

Excision  of,  drainage,  and  after-treatment,  307. 

Laminectomy, 309 

Closure  of  wound  and  postoperative  treatment,  309. 

Spina  Bifida, 310 

Postoperative  treatment  of,  310. 

Hypospadias  or  Ectopia  Vesica, '. 311 

Postoperative  management  of,  311. 

Symphysiotomy, 312 

Mechanical  aids  in,  312. 

Tuberculosis  of  the  Joints, 314 

Rest  cure  in,  314. — Mechanical  aids  in,  314. — Abscess  of  hip-joint,  English 
method  of  treatment,  315. — Postoperative  treatment  in  general,  316. — 
Phelps'  method  with  carbolic  acid,  317. — Bier's  treatment,  31S. — lodo- 
form-glycerin  injections  in  tuberculous  joints,  Ochsner's  method,  318. — 
Whitman's  method  of  treatment  in  hip  abscess,  320. — Relative  efficiency 
of  traction  and  splinting  in,  322. — Thomas  brace,  324. 


XU  CONTENTS. 

CHAPTER  XV. 

PAGE 

MODERN  TREATMENT  OF  COMPOUND   FRACTURES, 331-359 

Method  advocated  by  Nicholas  Senn,  333.— Drainage  and  counter-open- 
ings in,  335. — After-treatment  in  general,  336. — Antiseptic  irrigation  and 
continuous  irrigation  of  wounds,  337. — Compound  fracture  of  the  leg, 
340. — Immobilization  of  fractures,  341. — Postoperative  treatment  of  com- 
pound fractures  of  the  arm  at  or  near  the  elbow,  343. — Postoperative 
treatment  of  fractures  of  thigh,  344. — Ambulatory  treatment  of  fractures 
of  thigh,  346. — Fractures  in  childhood,  346. — Cabot's  posterior  splint, 
347. — Complications  during  and  after  repair  of  fractures,  349. — Postoper- 
ative treatment  of  fracture  of  patella,  356.— Expectant  or  nonoperative 
method  of  treatment,  357. — Restoration  of  function  of  joint,  358. 

CHAPTER  XVI. 
AMPUTATIONS, 361-385 

Remarks  by  Kocher  on  amputations  in  general,  363. — Value  of  periosteum 
in,  365. — Procedure  for  a  normal  operation,  367. — Value  of  typical  methods, 
369. — Postoperative  closed  and  open  methods  of  treatment,  369. — Author's 
method  of  dressing  after  amputation  of  thigh  or  leg,  371. — After-treat- 
ment of  septic  cases,  373. — Postoperative  complications,  374. — Faulty 
stumps,  374. — Postoperative  changes  following  amputations,  375. 

Amputation  at  Shoulder,  After-treatment, 377 

Interscapulothoracic  Amputation,  After-treatment, 377 

After-treatment  of  Amputation  at  Hip -joint, 377 

Prosthetic  considerations,  378. 

Amputation  of  the  Thigh,  After-treatment, 380 

Amputation  of  Fingers  and  Thumb, 381 

Amputation  of  Toes  or  Portions  of  Foot, 383 

CHAPTER  XVII. 

EXCISIONS  OR  RESECTIONS  OF   JOINTS, 389-406 

Excisions  of  Joints, : 389 

Kocher  method  of  excision,  389. — Essentials  of  after-treatment,  389. — 
Excision  of  shoulder-joint,  390. — Postoperative  treatment  of,  391. — Post- 
operative results,  392. — After-treatment  of  excision  of  elbow,  392. — Post- 
operative mechanical  aids  in,  393. 

Resection  of  Joints, 394 

Resection  of  wrist-joint,  394.— Resection  of  hip-joint,  general  considera- 
tions of,  395. — Postoperative  treatment  of,  396. — Ambulatory  splint  in, 
397. — Excision  of  knee-joint  and  postoperative  treatment,  398. — Cheyne's 
method  of  after-treatment,  400. — Excision  of  ankle-joint,  402. 

Result  of  Excision  Operations, 403 

Subperiosteal  method,  403. — Summary  of  postoperative  treatment,  404. 

CHAPTER  XVIII. 

OSTEOMYELITIS,     OPERATIONS    FOR     CLUB-FOOT,    OSTEOTOMY 

FOR  GENU  VALGUM,  ETC., 407-422 

Osteomyelitis, 409 

Chronic  osteomyelitis,  general  remarks,  B.  H.  Nichols,  409. — After-treat- 
ment, 411. 
Club-foot, 413 

Postoperative  treatment,  414. — Retention  brace,  415. — Taylor's  brace, 
416. 


CONTENTS.  XI 11 

TM.r. 

Talipes  Calcankus,  After-treatment, 4  r8 

Tendo  achillis,  transplantation  of,  419. 

Osteotomy  for  Curved  Tibia  and  Fibula, 420 

Stillman's  brace  in,  420. 

Osteotomy  for  Genu  Valgum,  Ai'Ter-treatment  oi--, 421 

Erichsen's  brace,  422. 

CHAPTER  XIX. 

VALUE    OF    RONTGEN-RAY    IN    POSTOPERATIVE    TREATMENT; 

MANNER  OF  APPLICATION, 425-435 

Rontgen-ray  Therapy, 425 

General  consideration,  425. — Dosage  and  method  of  treatment,  426. — 
Effects  of  treatment,  430. — Character  and  kind  of  tube,  431. — For  rectal 
and  vaginal  treatment,  434. — Types  of  epithelioma  curable  by  the  Ront- 
gen-ray treatment,  434. — Manner  of  protecting  patient,  435. 

CHAPTER  XX. 

COMPENSATIVE  OR  ARTIFICIAL  APPLIANCES, 435-446 

Where  and  how  to  amputate,  439. — In  amputation  of  leg,  440. — Ampu- 
tation of  thigh,  440. — Amputation  at  the  knee,  441. — The  position  of 
the  cicatrix,  442. — General  remarks  concerning,  444. — Preparation  of 
stump  for  artificial  limb,  445. — Artificial  hands  and  arms,  445. 

CHAPTER  XXI. 
POSTOPERATIVE   DIETETICS, 447-454 

General  rules  for  postoperative  feeding,  449. — Diet  for  laparotomy  pa- 
tients, 451. — After  operations  upon  stomach,  453.— After  operations  upon 
intestines,  452. — After  operations  upon  gall-bladder,  453. — After  opera- 
tions upon  mouth,  453. — After  operations  upon  head,  454. — Use  of  alco- 
hol after  operations,   454. — Feeding  of  nutrient  enemas,   454. 


Index, 457-468 


CHAPTER  I. 

PREPARATION  OF  PATIENTS  AND  OF  THE 
FIELD  OF  OPERATION. 


CHAPTER  I. 
PREPARATION  OF  THE  PATIENT. 

GENERAL  REMARKS. 

The  proper  preparation  of  patients  for  surgical  operation  is  of  such 
importance  and  has  such  bearing  upon  the  postoperative  treatment, 
that  we  shall  be  pardoned  for  devoting  the  time  and  space  necessary 
for  a  brief  review  of  the  subject.  The  rationale  of  preparatory  treat- 
ment is  based  upon  the  principle  that  the  entire  system  should  be  as 
nearly  normal  as  is  possible.  Robert  T.  Morris  says:  "All  the  avenues 
of  elimination  must  be  open  and  active,  in  order  to  overcome  condi- 
tions that  lead  to  autointoxication,  and  render  infection  the  more 
probable." 

If  digestion  is  faulty,  the  diet  should  be  restricted,  and  the  condition 
relieved.  If  the  liver  is  torpid  and  constipation  present,  laxatives  are  in- 
dicated, or  brisk  purgation  necessary,  in  order  that  the  intestinal  tract 
may  be  rid  of  toxic  matter.  Should  the  kidneys  be  at  fault,  the  judicious 
use  of  diuretics  may  prove  of  value.  A  general  bath  every  third  or  fourth 
day,  or  oftener,  with  friction  or  massage,  increases  the  action  of  the  skin 
and  relieves  the  kidneys.  The  plan  of  general  preparation  of  patient 
herein  advocated  is  that  which  is  uniformly  used  at  the  Eldora  Emer- 
gency Hospital,  and  applies  to  all  except  emergency  cases  in  which 
immediate  operation  is  imperative. 

The  patient  upon  entering  the  hospital  is  given  a  warm  bath,  or- 
dinary castile  soap  with  a  good  flesh-brush  being  sufficient.  If  the 
patient  is  a  female,  a  hot  douche  of  one  ounce  of  sodium  bicarbonate  to 
one  gallon  of  water  is  given,  followed  by  a  douche  containing  J  ounce 
of  creolin  to  one  gallon  of  water,  or  a  one  percent  solution  of  lysol ;  after 
which  the  patient  is  dressed  in  a  clean  gown  and  sent  to  a  room  or 
ward.  A  complete  history  of  the  case  is  obtained,  and  a  careful  physical 
examination  is  made  to  determine  the  nature  or  extent  of  the  operation 
required  and  the  general  condition  of  the  patient.  Should  this  examina- 
tion reveal  the  existence  of  phthisis,  Bright's  disease,  jaundice,  diabetes, 
or  any  other  condition  that  would  render  the  operation  unusually  haz- 


2  POSTOPERATIVE    TREATMENT. 

ardous,  the  preparatory  treatment  must  be  directed  specially  to  that  con- 
dition. 

A  chemic  (and  later,  if  necessary,  a  microscopic)  examination  of  the 
urine  is  made,  and  the  quantity  of  urine  passed  in  twenty-four  hours  is 
carefully  noted.  If  immediate  operation  is  not  necessary,  and  the  general 
health  of  the  patient  is  impaired,  she  is  at  once  placed  in  bed,  and  tonics 
and  restoratives  are  administered.  If  the  appetite  is  lost,  a  good  prepara- 
tion of  cod-liver  oil,  with  tincture  of  nux  vomica,  Colombo,  or  gentian,  is 
helpful.  If  the  urine  is  scanty  or  deficient  in  quantity,  copious  and  fre- 
quent drafts  of  water,  plain  or  carbonated,  are  insisted  upon,  and  are  of 
special  value  if  the  patient  is  a  nervous  woman.  Constipation  is  overcome 
by  the  daily  administration  of  compound  licorice  powder,  preparations  of 
cascara  sagrada,  or  compound  aloin  pills.  If  anemia  is  marked,  fresh 
gelatin-coated  Blaud's  pills  or  capsules,  with  or  without  arsenic,  have 
proved  in  our  hands  of  greater  value  than  many  of  the  modern  prepara- 
tions of  iron.  If  there  is  marked  debility  with  anemia,  not  dependent 
upon  hemorrhage  or  septic  conditions,  in  addition  to  the  above,  inunctions 
of  leaf  lard  (Boody)  applied  to  the  back,  chest,  and  inside  of  the  thighs, 
followed  by  massage,  with  daily  rectal  enemas  of  normal  salt  solution, 
will  prove  beneficial.  If,  however,  the  anemia  and  exhaustion  are  the 
result  of  hemorrhage,  exhaustive  discharges,  or  septic  absorption,  imme- 
diate operation  is  indicated,  after  which  the  system  will  be  in  better  con- 
dition and  respond  more  readily  to  tonics  and  restoratives  during  con- 
valescence. 

Five  or  six  days  prior  to  all  abdominal  operations  the  entire  intes- 
tinal tract  should  be  gently  but  thoroughly  evacuated.  A  calomel  purge, 
administered  in  the  evening  and  followed  the  next  morning  by  a  dose 
of  magnesium  sulfate  or  castor  oil,  is  usually  sufficient. 

Kelly  recommends  the  old-fashioned  black  draft  with  carminative; 
viz. : 

Magnesium  sulfate, o  j 

Senna, oiij 

Manna, 3ij 

Pulverized  cardamom  seed, O  j 

Boiled  water, Oj. 

Boil  and  strain,  and  give  2  ounces  every  two  hours. 

The  patient  is  then  placed  upon  a  highly  nourishing  liquid  diet  (soups 
and  broths),  but  no  milk  is  allowed.  On  the  evening  of  the  second  day 
preceding  the  operation  a  second  laxative  should  be  given,  in  order  that 
the  bowels  may  be  free  from  accumulations ;  and  during  this  time,  in  ad- 


PREPARATION   OF    THE    PATIENT.  3 

dition  to  tonics  and  reconstruct)' ves,  we  generally  prescribe  five-grain  doses 
of  beta-naphthol  bismuth,  preferably  in  capsules,  with  or  without  extract 
of  cascara  sagrada,  as  an  intestinal  antiseptic  and  laxative.  Patients 
very  much  exhausted,  or  those  advanced  in  years,  who  are  to  be  operated 
upon  early  in  the  morning,  may  require  nourishment  during  the  night; 
beef-tea  or  clear  soup,  and,  in  extreme  cases,  brandy  or  whisky  at  inter- 
vals of  three  or  four  hours,  may  be  given  with  advantage,  up  to  two  hours 
preceding  anesthesia.  The  evening  before  the  operation,  after  a  light 
supper,  another  bath  is  given,  after  which  the  patient  is  placed  in  bed, 
and  if  nervous,  twenty  to  thirty  grains  of  sodium  bromid  is  given  to 
induce  sleep.  No  food  or  broths  of  any  kind  are  allowed  during  the 
night,  but  the  next  morning,  not  later  than  four  hours  prior  to  the  ad- 
ministration of  the  anesthetic,  a  cup  of  hot  coffee,  black  tea,  or  beef  broth 
is  given;  otherwise  the  stomach  is  kept  empty.  No  purgatives  are  ad- 
ministered the  evening  before  the  operation,  nor  do  we  permit  flushing 
of  the  rectum  or  enemas  of  any  kind  on  the  morning  of  the  operation, 
as  they  frequently  annoy  both  patient  and  operator. 

METHODS  OF  PREPARATION  OF  PATIENT  BY  VARIOUS 

SURGEONS. 

For  Laparotomy.^Franklin  H.  Martin's  method  is  as  follows: 
The  intestines  are  emptied  by  mercurials  and  salines.  The  first 
night  of  preparation  six  grains  of  blue  mass  is  given.  The  next  morn- 
ing at  six  o'clock  seidlitz  powders  are  given  every  hour  until  the  bowels 
move,  or  feel  as  though  they  would  move  with  the  aid  of  a  small  enema. 
This  should  insure  a  thorough  action  throughout  the  entire  length  of 
the  intestinal  canal.  If,  with  the  above  treatment,  the  movements  are 
such  as  to  insure  a  thorough  evacuation  and  to  start  a  free  flow  of  bile, 
as  indicated  by  the  yellow,  glistening  appearance  of  the  stool,  no  further 
catharsis  is  necessary.  The  lower  bowel  should  be  thoroughly  evacu- 
ated, however,  by  the  employment  of  large  enemas  of  soap  and  water, 
repeated  four  or  five  times  during  this  second  day  of  preparation.  The 
last  enema  should  be  given  late  in  the  afternoon  of  the  second  day  of 
preparation,  if  the  operation  is  to  done  the  following  morning,  or  the 
next  morning  if  the  operation  is  to  be  done  in  the  afternoon.  The  bowels 
are  rendered  less  septic  by  large  doses  of  bismuth  and  salol.  During 
the  first  and  second  days  of  preparation  ten  grains  of  salol  and 
twenty  grains  of  bismuth  subnitrate  should  be  given  every  six  hours. 
The  bowels  are  stimulated  bv  means  of  carminatives,  alcoholic  stimu- 


4  POSTOPERATIVE    TREATMENT. 

lants,  and  strychnin.  The  second  day  of  preparation  oil  of  cloves, 
in  capsules,  is  given.  In  delicate  women  strychnin  is  commenced  three 
days  before  the  operation  in  ^-^p-grain  doses  every  eight  hours,  and  grad- 
ually increased  in  quantity  until  ^V'grain  doses  are  given.  The  bowels 
are  rendered  less  septic  by  feeding  the  patient  on  a  milk  diet  for  two 
days  before  the  operation. 

For  Laparotomy. — Ochsner's  method  is  as  follows: 

"As  a  rule,  long-continued  preparatory  treatment  leaves  the  patient 
in  a  much  less  favorable  condition  for  a  surgical  procedure  than  a  short 
and  simple  preparation,  which  serves  to  put  the  kidneys,  the  skin,  and 
the  alimentary  canal  in  condition  favorable  to  the  elimination  of  the 
waste  products. 

"Two  or  three  days  preceding  the  operation,  the  patient  should  be 
placed  on  a  light  diet  consisting  of  sterilized  food,  and  allowed  an  abun- 
dance of  good  water,  preferably  hot,  in  order  to  favor  elimination  through 
the  kidneys.  A  nonirritating  cathartic  should  be  given,  and,  if  possible,  a 
warm  general  bath.  For  several  years  I  have  given,  as  a  rule,  two  ounces 
of  castor  oil  in  the  foam  of  beer  or  malt  extract,  the  day  before  the  opera- 
tion, and  a  large  soap-and- water  enema  on  the  morning  of  the  operation. 
In  this  manner  the  patient  is  relieved  in  a  relatively  short  time  of  all 
waste  matter  and  is  measurably  removed  from  the  likelihood  of  absorb- 
ing the  products  of  decomposition  which  may  be  present  in  the  alimen- 
tary tract.  So  large  a  dose  of  castor  oil  does  not,  as  a  rule,  give  rise 
to  great  disturbance,  pain,  or  exhaustion.  I  have  also  found  that  the 
foam  of  beer  or  malt  extract  disguises  the  oil  so  thoroughly  that  patients 
who  are  ordinarily  nauseated  will  bear  this  without  annoyance.  In 
the  vast  majority  of  patients  this  amount  of  preparation  suffices  to  re- 
lieve the  body  of  any  burden  it  may  possess  which  might  interfere  with 
the  process  of  healing.  In  other  words,  the  patient  approaches  the  opera- 
tion in  a  comparatively  clean  condition;  his  strength  has  not  been  im- 
paired by  confinement,  and  the  nervous  system  has  not  suffered  by  look- 
ing forward  to  the  operation  for  a  long  time." 

For  General  Surgical  Operations. — Dr.  Joseph  Price,  of  Phila- 
delphia, says:  "There  are  two  •considerations  to  be  borne  in  mind  in 
the  preparation  of  patients  for  operation.  In  Europe  and  America  it  is 
the  rule  to  admit  the  patient  to  the  hospital  a  few  days  before  the  oper- 
ation is  to  be  performed:  (i)  In  the  interval  between  admission  and 
operation  the  patient  is  bathed,  scrubbed,  douched  if  the  operation  will  in- 
volve in  any  way  the  vaginal  tract,  and  is  purged  with  calomel  and  ro- 


PKKI'AFMTION    OF    TIIK    PATIKNT.  5 

chelle  salts.  (2)  The  proper  preparation  for  jjlastic  work,  in  ufUlition 
to  that  which  is  required  for  general  surgical  procedures,  requires  especial 
brush-scrubbing  and  irrigating  of  the  mucous  passages;  and  that  all  scar- 
tissue  should  be  freed  to  favor  easy  approximation  of  the  walls  of 
fistulas. 

"In  abdominal  work  purgation  conduces  to  favorable  postoperative 
conditions,  prevents  bowel  distention,  reverse  peristalsis,  persistent  nausea 
and  vomiting,  and  renders  unnecessary  the  premature  administration 
of  laxatives ;  in  short,  the  emptied  bowel  is  at  rest,  as  it  should  be,  for 
the  first  twenty- four  to  thirty-six  hours  after  operation.  If  the  bowel 
is  thoroughly  emptied  and  bathed  with  bile,  fermentation  and  conse- 
quent distention  do  not  occur.  To  fortify  the  statement  that  thorough 
preparation  previous  to  operation  is  necessary  I  may  add  that  In  100 
patients  brought  into  the  hospital  suffering  from  such  conditions  as  sup- 
purative tubo-ovarian  disease,  diseases  of  the  uterus  rendering  hysterec- 
tomy necessary,  appendicitis,  gallbladder  disease,  etc.,  and  prepared 
during  two  days  and  a  night  previous  to  operation,  there  was  no  per- 
ceptible distention  in  any  case,  and  no  alarming  postoperative  compli- 
cations. 

"It  is  an  error  to  administer  purgatives  and  enemas  soon  after  opera- 
tion, or.to  resort  to  other  persistent  eilorts  to  move  the  bowel;  this  should 
have  been  accomplished  before  operation,  by  the  use  of  calomel  and 
rochelle  salts,  since  these,  in  my  opinion,  give  the  best  results.  Further- 
more, calomel  stimulates  hepatic  activity,  and  tlie  presence  of  plenty 
of  bile  in  the  lower  bowel  prevents  fermentation  and  greatly  lessens  the 
tendency  to  distention. 

' '  The  '  let  alone '  treatment  after  operation  gives  the  best  results,  but 
the  free  use  of  fluids  before  operation  stimulates  the  circulation,  flushes 
out  the  kidneys,  and  increases  the  elimination  of  toxins.  It  is  interest- 
ing to  note  that  surgeons  who  prepare  their  patients  after  the  above 
method,  and  witlihold  drink  (?)  for  the  first  twenty-four  hours  after  sec- 
tion, have  the  largest  records  for  renal  secretion  in  ounces,  viz.,  an  ounce 
or  more  each  hour.  Withholding  fluids  ( ?)  after  operations  requiring 
drainage,  favors  the  early  removal  of  the  drains. 

"The  peritoneum  is  a  huge  lymph  sac  and  it  rapidly  digests  healthy 
and  noninfectious  exudates.  This  prevents  the  accumulation  of  such 
leakage  or  exudate,  and  hinders  the  development  of  more  virulent  germs. 
Leakage  from  perforation  is  primarily  safe,  but  later  germs  develop  in 
the  form  of  savages,  and  it  requires  drains  or  gill-nets  to  capture  them." 


6  POSTOPERATIVE    TREATMENT. 

Treves'  Method  of  Preparation. — Sir  Frederick  Treves'  method 
is  as  foUo'W's; 

Period  Before  the  Operation.^ — "The  most  thorough  examina- 
tion possible  of  the  patient  should  be  made  before  an  operation  is 
undertaken.  To  carry  this  out,  it  is  well  that  the  individual  should  be 
under  observation  for  some  time  before  he  appears  in  the  operating 
room.  In  the  case  of  those  who  have  been  long  confined  to  bed,  it  is 
obvious  that  the  sooner  they  are  relieved,  the  better.  On  the  other 
hand,  in  the  matter  of  operations  of  expediency  upon  patients  who  may 
be  termed  healthy,  it  is  well  that  they  should  pass  through  a  period  of 
rest  before  the  operation  is  performed.  Operations  hurriedly  under- 
taken are  not  unfrequently  regretted. 

"■  In  hospital  practice  it  is  better  not  to  operate  upon  a  man  who  comes 
straight  to  the  wards  from  some  active  outdoor  work,  who  is  robust  and 
has  been  living  heartily,  and  who  has  still  the  vigorous  throb  of  exercise 
in  his  blood  and  in  his  limbs.  The  practice  is  frequent,  for  the  opera- 
tion has  been  previously  arranged,  and  the  man  does  not  want  to  lose 
even  a  few  hours'  work.  Such  a  patient  is  placed  in  an  infinitely  better 
condition  by  a  few  days'  rest  in  a  hospital  ward.  He  here  becomes 
accustomed  to  his  surroundings ;  he  has  time  to  be  rid  of  the  refuse  matter 
in  his  tissues,  which  can  no  longer  be  cast  off  by  muscular  exertion;  his 
hearty  appetite  is  enabled  to  adapt  itself  to  his  present  requirements; 
the  excreta  can  be  dealt  with;  and  time  is  allowed  (and  it  is  needed  in 
some  hospital  patients)  to  make  clean  the  skin.  To  all  the  organs,  to 
the  still  strongly-beating  heart,  and  to  the  overworked  muscles,  there 
is  allowed  a  period  of  repose.  When  the  operation  day  arrives,  the  pa- 
tient has  become  acclimatized,  strict  confinement  to  bed  and  a  limited 
diet  do  not  involve  so  very  sudden  a  change,  he  has  adjusted  himself 
to  his  new  environment,  and  the  ordeal  is  met  after  a  period  of  physio- 
logic rest. 

"Many  small  operations  would  do  better  if  the  patient  would  con- 
sent to  the  preliminary  of  a  few  days'  rest.  This  is  conspicuous  often 
in  operations  upon  piles,  when  the  subject  persists  in  absorbing  him- 
self with  his  work  up  to  the  time  of  the  operation.  Often  a  business 
man  will  overwork  himself  desperately  before  his  operation,  in  order 
that  his  affairs  may  not  suffer  in  his  absence. 

"What  is  worth  doing  at  all  is  worth  doing  well,  and  not  a  few  opera- 
tions, the  performance  of  and  recovery  from  which  have  to  be  com- 
pressed within  a  few  hurried  days,  would  better  not  be  performed  at  all. 


PREPARATION    OF    FIELD    OF    OPERATION.  7 

In  the  case  of  women  wilh  long  hair,  the  \'ariou.s  coils  and  twists  should 
be  undone,  the  whole  hair  parted  behind  in  the  median  line  and  dis- 
posed of  in  two  simple  lateral  plaits.  The  hair  is  thus  kept  out  of  the 
way — should  the  operation  concern  the  head  and  neck — and  after  the 
operation  the  head  can  rest  comfortably  upon  the  natural  scalp,  and 
not  upon  a  comphcated  mound  of  wisps  of  hair,  hairpins,  and  other 
foreign  substances." 

Diet. — "The  practice  of  starving  a  patient  before  an  operation  is 
undoubtedly  unwise.  The  amount  of  the  food  should  be  suited  to  the 
condition  of  an  individual  who  is  inert  and  within  doors.  It  should  be 
nutritious,  but  small  in  bulk,  and  not  of  a  character  to  leave  much  debris 
in  the  intestines.  Entire  abstinence  from  alcohol  for  a  week  or  more 
before  an  operation  might  prove  very  judicious  in  not  a  few  instances. 
The  patient  who  '  keeps  himself  up '  by  spirits  before  an  operation  is 
preparing  for  himself  a  sore  down-going  after  the  event  is  over." 

The  Bowels. — "The  bowels  should  be  well  opened  on  the  eve  of  the 
operation;  and  this  is  best  effected  by  an  aperient  overnight  and  an 
enema  in  the  morning." 

PREPARATION  OF  FIELD  OF  OPERATION. 

GENERAL  REMARKS. 

General  Preparation  of  the  Field  of  Operation. — The  field  of 
operation  requires  special  attention.  The  skin,  if  hairy,  should  be  care- 
fully shaved,  or  preferably  a  depilatory  should  be  applied;  after  this  the 
parts  are  thoroughly  scrubbed  with  green  soap  and  a  sterile  flesh-brush. 
If  the  integument  is  oily,  calloused,  or  very  dirty,  gasoline,  sulfuric  ether, 
or  turpentine  may  be  required,  but  ordinarily  green  soap  suffices.  The 
parts  are  then  washed  with  alcohol  until  all  traces  of  the  soap  and 
other  foreign  substances  have  disappeared.  This  is  followed  by  a  i :  2000 
solution  of  corrosive  sublimate  if  the  skin  is  not  broken,  and,  lastly,  the 
parts  are  flushed  with  sterile  water.  The  entire  part  or  field  of  opera- 
tion is  then  covered  with  several  layers  of  sterile  gauze,  moistened  with 
a  1 :  4000  mercuric  chlorid  solution,  over  which  a  sterile  bandage  is  applied. 
This  procedure  applies  to  amputations  in  general,  and  to  all  operations  on 
the  chest,  arms,  limbs,  hands,  or  feet.  In  operations  upon  the  face, 
the  eyebrows,  beard,  and  mustache,  if  in  the  line  of  incision,  should  be 
carefully  shaved,  the  scalp  being  thoroughly  cleansed  and  washed  as 
above  directed,  after  which  a  moist  antiseptic  gauze  dressing  covering 


8  POSTOPERATIVE    TREATMENT. 

the  entire  scalp  or  head  is  appHed  and  held  in  place  by  a  bandage,  which 
is  not  removed  until  the  moment  of  operation.  In  operations  upon  the 
head,  if  not  extensive,  clipping  of  the  hair  to  facilitate  cleansing,  and 
shaving  the  part  immediately  involved,  will  suffice. 

The  Eye. — The  eyebrows  should  be  shaved,  and  adjacent  parts, 
especially  the  lids  and  orifice  of  the  lacrimal  ducts,  carefully  cleansed 
with  a  boric  acid  solution,  after  which  a  pad  of  sterile  cotton  saturated 
with  a  solution  of  boric  acid  should  be  apphed  and  held  in  position  by  a 
bandage. 

Mouth,  Nose,  and  Throat.- — In  these  regions  antiseptics  in  solu- 
tion strong  enough  to  be  of  value  cannot  be  used.  Miller  has  demon- 
strated that  carbolic  acid,  boric  acid,  and  potassium  chlorate  are  of 
little  value.  The  routine  followed  at  the  Massachusetts  General  Hos- 
pital is  as  follows :  Several  days  before  the  operation  the  patient's  teeth 
are  examined  by  a  dentist  and  thoroughly  cleaned.  Cavities  are  filled 
and  all  decayed  teeth  are  removed.  The  cleaning  and  sterilizing  are 
continued  by  rinsing  the  mouth  and  brushing  the  teeth,  especially  about 
the  roots,  several  times  a  day  with  an  antiseptic  solution.  The  pharynx, 
tonsils,  and  nose  should  be  sprayed  at  the  same  time,  and  this  treatment 
continued  two  or  three  times  daily  until  just  before  the  operation.  (War- 
ren, "Surgical  Pathology.") 

The  following  formula  has  been  suggested  by  Miller: 

Saccharin, 5  ss 

Benzoic  acid, gr.  xlv 

Tincture  of  ratanhia, oss 

Absolute  alcohol,   o  iiiss 

Oil  of  peppermint, ' gtt.  v 

Oil  of  cinnamon, gtt.  iv.  M. 

SiG. — Dilute  with  ten  parts  water,  or,  better,  ten  parts  of  a  4  percent  solution  of 
hydrogen  dioxid,  and  hold  in  the  mouth  for  one  minute,  or  use  as  a  spray. 

For  Stomach  Operation. — ^W.  J.  Mayo's  method  is  as  follows : 
A  week  or  ten  days  prior  to  the  operation,  unless  contraindicated 
by  exhaustion  or  disease,  the  patient  is  given  once  daily,  before  breakfast, 
lavage  of  the  stomach  with  normal  salt  solution  or  boric  acid  solution,  for 
the  double  purpose  of  mild  disinfection,  and  teaching  the  patient  to  become 
accustomed  to  the  tube.  He  is  placed  upon  a  nourishing  liquid  diet, 
exclusive  of  milk.  Owing  to  the  great  emaciation  of  many  of  these  pa- 
tients, rectal  alimentation  as  well  as  hypodermoclysis  is  often  necessary. 
The  night  before  the  operation  castor  oil  is  administered,  and  if  the 
stomach  is  not  empty,  it  is  carefully  washed  out  in  the  morning,  preced- 
ing the  administration  of  the  anesthetic. 


PREPARATION    OF    FIELD    OF   OPERATION.  9 

Cervix  and  Uterus. — The  same  method  of  cleansing  or  [^reparation 
as  for  vaginal  operations  should  be  done,  and  it  is  our  custom  in  all 
operations  upon  the  cervix,  when  the  patient  is  under  anesthesia,  first 
to  dilate  and  curet  carefully  the  cavity  of  the  uterus  before  proceeding 
with  the  operation  proper. 

For  Operation  on  Bladder,  Urethra,  and  Kidneys. — Salol  or 
urotropin  should  be  administered  in  regular  doses  of  seven  and  one-half 
to  ten  grains,  three  times  a  day,  for  the  purpose  of  disinfecting  the  uri- 
nary tract.  The  patient  should  be  induced  to  drink  large  quantities  of 
water.  The  morning  of  the  operation  the  bladder  and  urethra  require 
thorough  cleansing  through  a  double  catheter  by  means  of  irrigation 
with  boric  acid  or  Thiersch's  solution.  This  is  best  accomplished 
when  the  patient  is  under  anesthesia. 


PREPARATION    OF   THE   FIELD    BY  DIFFERENT 
SURGEONS. 

Howard  Kelly's  method  is  as  follows  ("Operative  Gynecology," 
D.  Appleton  &  Co.) : 

In  order  that  the  field  of  operation  may  be  rendered  as  nearly  asep- 
tic as  possible  before  the  patient  is  taken  to  the  operating  room,  the  most 
active  disinfecting  measures  are  employed.  All  of  the  articles  necessary 
for  cleansing  the  abdomen  are  placed  in  convenient  reach.  Usually  a 
small  stand  is  placed  near  the  bed,  and  upon  this  are  placed  green  soap, 
flasks  of  water  and  of  mercuric  chlorid  solution  (i :  looo),  a  package  of 
sterile  towels,  gauze,  scrubbing  mops,  alcohol,  and  ether.  The  abdomen 
is  well  exposed,  the  bed  and  clothing  above  and  at  the  sides  being  pro- 
tected by  a  rubber  sheet.  The  skin  from  the  ensiform  process  to  just 
above  the  pubes  is  lathered  with  green  soap  and  water,  and  shaved  well  out 
from  the  median  line.  If  an  abdominal  incision  is  to  be  made  in  any 
locality  other  than  the  median  line,  the  nurse  is  so  instructed,  and  varies 
the  site  of  shaving  accordingly.  After  shaving,  the  skin  is  thoroughly 
scrubbed  with  a  gauze  mop.  If  the  patient  is  a  nervous,  delicate,  re- 
fined woman,  the  shaving  would  best  be  done  on  the  operating  table 
when  she  is  unconscious. 

The  nurse  now  suspends  the  preparation  while  she  disinfects  her 
own  hands,  after  which  the  skin  is  thoroughly  rubbed  and  washed  ^^dth 
alcohol,  then  ether,  and  finally  with  a  i :  looo  mercuric  chlorid  solution.  A 
large  sterile  gauze  shield  is  tied  by  conveniently  placed  tapes  over  the 


lO  POSTOPERATIVE    TREATMENT. 

abdomen,  and  the  patient's  toilet  is  completed  by  putting  on  a  clean 
nightgown.-  If  she  is  nervous  or  feels  weak,  a  wine-glass  of  sherry  or  a 
small  milk-punch  is  given. 

The  first  step  toward  disinfection  in  any  abdominal  case,  after  the 
patient  is  put  upon  the  table  and  placed  under  anesthesia,  is  the  thorough 
cleansing  of  the  vagina,  by  raising  and  separating  the  legs  and  applying 
soap  and  warm  water  vigorously,  with  a  pledget  of  sterilized  cotton  held 
in  the  grasp  of  a  pair  of  long  dressing  forceps.  This  step  need  not  be 
carried  out  in  a  young  woman  with  an  intact  hymen.  A  large  funnel 
or  an  open  speculum  may  be  placed  between  the  thighs  close  to  the  body 
to  facilitate  drainage  of  fluids  which  run  down  from  the  abdomen  on  to 
the  pad.  The  patient's  clothes  are  drawn  well  above  the  upper  border 
of  the  pad,  her  arms  are  flexed  and  folded  on  the  chest,  and  retained  in 
this  position  by  the  undervest  being  pulled  up  over  them,  and  by  tying 
the  wrists  together  with  a  gauze  bandage.  The  chest  is  protected  by  a 
blanket  with  a  rubber  sheet  over  it,  and  the  legs  are  warmly  wrapped 
in  a  blanket  and  sheet  in  like  manner.  If  the  operation  will  be  long, 
the  feet  should  rest  upon  a  hot-water  bag,  and  another  should  be  placed 
under  the  knees,  and  still  others  about  the  chest.  For  feeble  patients, 
I  use  long,  narrow  hot- water  bags  encased  in  flannel,  and  reaching  from 
the  armpits  to  the  knees. 

Cleansing  the  Abdomen. — The  temporary  protective  gauze  ban- 
dage, before  referred  to,  is  now  removed  by  the  nurse,  and  an  assistant, 
with  sterilized  hands,  proceeds  to  scrub  the  abdomen  with  sterilized 
cotton  balls  enveloped  in  gauze,  applying  soap  and  water  freely  for 
several  minutes.  Special  care  should  be  observed,  both  in  the  prelimi- 
nary preparation  in  the  ward  and  upon  the  operating  table,  in  cleans- 
ing the  folds  of  the  umbilicus,  when  it  is  deep,  using  absorbent  cotton 
held  in  forceps.  Following  the  soap  and  water,  the  abdomen  is  scrubbed 
with  ether,  and  after  this  with  alcohol,  and  finally  with  a  mercuric  chlorid 
solution  (i:iooo).  Before  disinfecting  the  abdomen  of  unusually 
fat  women,  the  creases  formed  by  the  overhanging  cutaneous  folds 
should  be  inspected  for  a  slight  dermatitis  or  eczema,  which  often  exists. 
Unless  the  operation  is  imperatively  demanded,  these  areas  should  be 
entirely  healed  before  an  incision  is  made  through  the  abdomen,  as  such 
apparently  insignificant  surface  lesions  may  conceal  virulent  organisms. 

Arranging  the  Field  of  Operation. — Sterilized  towels  are  now 
laid  upon  the  rubber  sheets  on  the  chest  and  thighs  and  on  the  sides  of 
the  abdomen,  completely  covering  them;    a  piece  of  sterilized  gauze, 


PREPARATION    OF    I'IKLD    OF    OPERATION.  II 

four  layers  thick  and  i  meter  (i  yard)  square,  or  a  sheet  marie  ffjr  the 
purpose  witli  a  hole  in  the  middle,  is  laid  over  the  |)aticnt  from  breast 
to  knees;  finally,  two  sterilized  towels  are  spread  above  and  below  over 
the  ends  of  the  cover.  A  wire  bracket  resting  on  the  patient's  thighs 
and  covered  with  sterilized  towels  serves  as  a  convenient  receptacle  for 
the  instruments  which  the  operator  needs  to  have  close  at  hand  if  the 
operation  is  done  with  the  patient  in  the  horizontal  posture.  I  provide 
for  this  when  the  pelvis  is  elevated  by  turning  over  the  end  of  a  towel 
stretched  across  the  thighs,  and  clamping  it  to  the  sheet  so  as  to  make 
a  shallow  pocket,  in  which  the  instruments  rest. 

Joseph  Price's  Method  in  Abdominal  Preparation. — The 
method  of  preparing  for  abdominal  section  employed  by  Dr.  Joseph 
Price,  of  Philadelphia,  is  as  follows : 

The  patient  is  given  a  hot  soap-and- water  bath,  the  skin  of  the 
body  being  thoroughly  scrubbed  with  the  bath-brush;  a  shampoo  is 
given  and  the  nails  are  manicured;  the  field  of  operation  is  thoroughly 
scrubbed  with  soap  and  water;  this  is  followed  by  turpentine ;  and  this  in 
turn  by  alcohol.  A  gauze  towel  is  now"  wrung  out  of  an  acid  solution 
of  mercuric  chlorid,  placed  over  the  field  of  operation,  and  left  in 
this  situation  beneath  the  bandage,  overnight.  The  site  of  incision 
is  painted  with  iodin  (MacDonald's  method)  to  lessen  the  tendency  to 
stitch-hole  abscesses. 

This  thorough  external  and  internal  preparation  would  cause  many 
patients,  in  some  countries,  particularly  the  Orient,  to  leave  the  hospital 
in  fear  of  the  operation.  And  even  in  our  own  country  it  not  infrequently 
happens  that  thorough  purgation  and  rest  will  so  relieve  patients  suf- 
fering from  tubo-ovarian  disease  that  they  will  refuse  operation,  only 
to  return  later  when  the  bowel  is  again  distended  and  the  pelvic  organs 
again  congested. 

In  India  some  good  surgeons  avoid  extensive  preparation  of  their 
patients  because  of  the  alarm  thus  induced. 

Careful  or  severe  preparation  of  patients  favors  comfortable  and 
speedy  convalescence,  and  a  total  absence  of  many  of  the  uncomfortable 
postoperative  complications,  such  as  distention,  persistent  nausea  and 
vomiting,  scant  renal  secretion,  elevation  of  temperature,  sleeplessness, 
and  other  conditions  which  are  thought  to  indicate  the  employment  of 
opium. 

Nicholas  Senn's  Method  of  Disinfection  of  Field  of  Operation 
or  Injury  is  as  follows: 


12  POSTOPERATIVE    TREATMENT. 

"  In  important  operations  I  have  relied  for  several  years  on  tur- 
pentine in  preparing  the  surface  for  the  antiseptic  solution.  After 
a  thorough  cleansing  with  soap  and  water  the  skin  is  bathed  with  tur- 
pentine for  a  minute,  when  warm  water  and  potash  soap  are  used  to 
remove  the  turpentine,  after  which  the  surface  is  ready  for  the  efficient 
use  of  the  antiseptic  solution.  Next  to  soap  and  hot  water  the  razor 
is  most  important  in  disinfection  of  the  surface  of  the  skin  preparatory 
to  the  application  of  the  antiseptic  solution.  The  razor  not  only  re- 
moves hair,  but  also  scrapes  away  the  superficial  layer  of  the  epidermis, 
softened  and  macerated  by  scrubbing  with  hot  water  and  potash  soap. 
In  operations  of  choice  the  skin  may  be  properly  prepared  for  a  more 
efficient  use  of  the  razor  and  brush  by  applying  to  the  surface  to  be  pre- 
pared a  soft-soap  poultice  for  a  few  hours.  This  preliminary  measure 
to  macerate  the  skin  is  of  special  importance  in  preparing  the  scalp, 
scrotum,  hands,  and  feet  for  operation.  One  of  the  commonest  faults 
in  preparing  the, surface  for  operation  is  that  the  disinfection  is  not  carried 
far  enough.  For  instance,  in  the  treatment  of  compound  fractures  of 
the  skull  it  is  not  an  unusual  practice  to  limit  the  shaving  and  disinfec- 
tion to  the  site  of  the  wound.  In  all  operations  on  the  skull  the  whole 
scalp  should  be  shaved  and  disinfected.  Women  usually  protest  against 
such  a  procedure,  but  when  informed  that  this  is  done  as  much  for  cos- 
metic as  for  surgical  reasons,  the  objections  are  overcome.  Every  pa- 
tient can  expect  a  fair  growth  of  hair  before  he  recovers  from  the  effects  of 
the  injury  or  operation.  Disinfection  for  an  amputation  of  the  breast 
should  include  the  whole  chest  and  the  shoulder  and  arm  on  the  side  of 
the  breast  to  be  removed.  In  abdominal  operations  the  whole  abdo- 
men, including  the  pubic  region  and  the  chest  as  far  as  the  breasts,  must 
be  prepared.  In  amputations  of  the  leg,  the  leg  from  the  seat  of  injury 
or  disease  and  the  thigh  must  be  shaved  and  disinfected.  In  amputa- 
tions of  the  thigh,  the  pelvis  on  the  corresponding  side  is  included  in  the 
preparation.  In  operations  for  hernia,  the  abdomen  as  far  as  the  um- 
bilicus, the  scrotum,  penis,  and  the  groin  constitute  the  field  of  opera- 
tion requiring  disinfection. 

"  In  operations  of  choice  the  disinfection  should  be  made  the  day 
preceding,  and  the  field  of  operation  covered  with  a  compress  wrung 
out  of  a  hot  antiseptic  solution,  either  a  2.5  percent  of  carbolic  acid, 
or  a  1 :  1000  solution  of  mercuric  chlorid ;  moisture  and  heat  are  re- 
tained by  applying  around  the  compress  a  ring  of  absorbent  cotton  and 
over  it  guttapercha  tissue  or  waxed  paper,  and  the  whole  held  in  place 


PRTCPARATION    OF    IIKLI)    OF   OPERATION.  I3 

by  a  gauze  bandage.  The  disinfection  is  repeated  after  the  patient  is 
under  the  influence  of  the  anesthetic  and  before  he  is  placed  on  the  oper- 
ating table.  In  emergency  operations  the  disinfection  is  done  after 
the  patient  has  been  placed  under  the  influence  of  the  anesthetic,  to 
avoid  delay  and  prevent  one  of  the  causes  of  shock. 

"Disinfection  of  mucous  surfaces  is  still  more  difficult  than  of 
the  skin.  As  a  rule,  complete  asepsis  cannot  be  secured  by  any  of 
the  methods  in  use  at  the  present  time,  and  in  consequence  of  the  in- 
complete disinfection  we  are  generally  forced  to  abandon  all  attempts 
to  obtain  primary  union  of  the  wound  throughout.  Irrigation  of  the 
vagina  or  rectum  with  any  of  the  more  potent  antiseptic  solutions  has  no 
effect  whatever  on  the  bacteria,  and,  besides,  by  doing  so  we  incur  the  im- 
mediate risk  of  serious,  if  not  fatal,  intoxication  by  the  rapid  absorption 
from  the  mucous  surfaces  of  the  toxic  agent  contained  in  the  solution. 
In  the  disinfection  of  mucous  surfaces  mechanical  measures  must  be 
relied  upon  in  preparing  the  parts  for  the  operation,  followed  by  the 
use  of  mild  nontoxic  solutions,  such  as  Thiersch's  solution  or  a  saturated 
solution  of  boric  acid."  ("Practical  Surgery,"  by  Nicholas  Senn,  W.  B. 
Saunders  &  Co.) 

Treves'  Method  of  preparing  the  site  of  operation  is  as  follows : 

The  Preparation  of  the  Skin. — "Care  should  be  taken  that  the 
patient's  body  is  clean.  This  is  a  surgical  necessity  of  the  utmost  impor- 
tance. A  warm  bath  the  night  before  the  operation  is  desirable  when- 
ever possible,  and  a  source  of  comfort  to  the  patient.  If  time  permits, 
the  operation  area  should  be  repeatedly  washed  for  some  days  before 
the  operation.  Some  hours  before  the  patient  is  brought  to  the  theatre 
the  skin  of  the  operation  area  should  be  specially  treated  with  a  view 
to  removing  or  rendering  harmless  the  ubiquitous  micrococci.  The 
following  is  one  of  many  plans  followed: 

"i.  If  a  hairy  part,  the  skin  should  be  carefully  shaved. 

"2.  With  soap  and  hot  water  a  thorough  mechanical  cleansing  should 
be  carried  out.  This,  however,  will  not  destroy  germs  in  the  epidermis 
or  remove  fatty  matter. 

"3.  With  ether  or  turpentine  the  skin  is  well  rubbed,  and  again 
washed  with  soap  and  water.  Sterilized  nail-brushes  should  be  used 
if  possible,  but  where  the  skin  is  tender  or  thin  this  cannot  be 
done.  'Rubber-sponges'  are  very  convenient.  Turpentine  is  more 
irritating  than  ether,  and  the  latter  should  be  used  by  choice. 

"4.  With  gauze  or  wool  sponges  soaked  in  an  alcoholic  solution  or 


14  POSTOPERATIVE    TREATMENT. 

carbolic  acid  (i  in  20),  or  bichlorid  of  mercury  or  mercuric  potassium 
iodid  (i  in  500),  the  part  is  rendered  really  aseptic.  A  mixture  of  i 
in  20  carbolic  acid  and  i  in  500  bichlorid  of  mercury  is  very  efficient, 
but  the  solution  must  be  made  with  alcohol  and  not  with  water.  The 
mercuric  potassium  iodid  solution  i  in  500  in  rectified  or  methylated 
spirit  has  many  advantages.  It  is  very  easily  prepared,  it  is  less  toxic 
than  corrosive  sublimate ;  it  does  not  corrode  plated  instruments,  and 
it  neither  roughens  nor  irritates  the  skin.  Its  germicidal  powers  are 
equal  to  those  of  corrosive  sublimate. 

"5.  Moist,  sterilized  gauze  or  lint  (soaked  in  a  i  in  60  solution  of 
carbolic  acid)  should  then  be  applied  under  waterproof  tissue,  bandaged 
on,  and  not  touched  until  the  patient  is  on  the  operating  table.  It  is 
easy  to  attach  undue  importance  to  this  antiseptic  compress.  It  merely 
protects  the  part,  and  so  macerates  the  skin  that  the  surface  epithelium 
can  be  rubbed  off  at  the  last  moment.  Aqueous  solutions  are  practi- 
cally powerless  against  organisms  in  the  epidermis. 

"6.  When  the  compress  is  removed,  immediately  before  the  actual 
incision  is  made,  it  is  a  useful  precaution  to  go  over  the  area  again  with 
the  alcoholic  solution  mentioned  above.  Finally,  the  skin  is  wiped  dry 
with  sterile  swabs.  In  certain  regions,  such  as  the  scrotum  or  eyelids, 
this  cannot  be  done,  and  it  may  be  said  that  it  is  impossible  to  render 
the  scrotum  really  aseptic.  The  axilla  is  also  a  most  difficult  region 
to  make  surgically  clean."  ("Operative  Surgery,"  Sir  Frederick  Treves, 
Lea  Bros.  &  Co.) 

Keen's  Method  of  Preparation  for  Cerebral  Operations  is  as  fol- 
lows: 

It  is  always  of  the  utmost  importance  that  the  head  should  be  shaved. 
This  will  often  reveal  scars,  etc.,  hitherto  unsuspected,  and  no  definite 
diagnosis  should  ever  be  reached  or  an  operation  determined  upon  with- 
out this  procedure.  The  fissures,  so  far  as  is  necessary,  may  be  marked 
out  on  the  shaven  scalp  by  means  of  an  anilin  pencil,  which  is  itself  anti- 
septic. The  day  before  the  operation  the  head  should  be  shaved  anew, 
if  need  be,  scrubbed  with  soap  and  water,  next  cleansed  with  ether,  and 
then  a  moist  bichlorid  (i :  2000)  dressing  applied.  The  dressing  should 
be  retained  in  place  until  just  before  the  operation,  when  it  should  be 
removed  and  the  disinfection  repeated.  Of  course,  the  general  prepa- 
ration of  the  patient,  as  regards  rest,  diet,  bathing,  and  the  bowels,  has 
been  attended  to  as  before  any  major  operative  procedure.  In  emer- 
gency cases,  however,  the  entire  preparation  must  usually  be  done  under 


PREPAKATION    OF    FIKI.D    OF    OPERATION.  1 5 

anesthesia,  but  here,  as  before,  the  entire  scalp  must  be  shaved,  and 
the  scalp  cleansed,  as  above,  with  scru|)u]ous  care. 

Ochsner's  Method. — "The  important  point  in  preparing  a  surface 
for  operation  lies  in  thorough  washing  with  soap  and  water;  anything 
that  is  done  beyond  this  is  of  little  importance,  provided  the  washing 
process  has  been  done  carefully  and  thoroughly.  In  my  practice  the 
steps  taken  in  preparing  the  field  of  operation  are  as  follows:  (i) 
thorough  scrubbing  with  soft  soap  and  warm  water,  with  a  moderately 
stiff  brush;  (2)  washing  the  surface  with  a  piece  of  aseptic  gauze  with 
fresh  water,  because  the  epithelial  scales  which  have  been  loosened  with 
the  brush  are  easily  removed  in  this  manner;  (3)  soaping  and  shaving 
the  field  of  operation;  (4)  washing  again  with  aseptic  gauze  and  ster- 
ilized water;  (5)  washing  the  surface  with  commercial,  i.e.,  about  95 
percent  alcohol;  (6)  washing  with  a  solution  of  corrosive  sublimate, 
1 :  2000.  There  is  still  a  distinct  superstition  in  favor  of  the  use  of  some 
antiseptic  fluid  for  washing  the  field  of  operation,  and  so  long  as  the 
fluid  employed  is  harmless,  I  believe  we  are  justified  in  using  it.  If 
this  preparation  of  the  patient  is  made  just  before  beginning  the  opera- 
tion, it  will  suffice;  if  made  on  the  day  before  the  operation,  the  surface 
must  be  protected  against  reinfection  during  the  intervals.  This  can 
be  done  by  applying  sterile  cotton  or  gauze  to  the  surface,  holding  it 
in  place  by  means  of  a  carefully  applied  bandage.  Just  before  the  opera- 
tion the  surface  is  once  more  washed  with  a  piece  of  sterile  gauze  satu- 
rated with  alcohol,  and  is  then  ready  for  operation."  ("Clinical  Sur- 
gery," A.  J.  Ochsner,  Cleveland  Press.) 

Preparation  of  the  Field  of  Operation  by  Means  of  a  Germi- 
cidal Depilatory. — Robert  T.  Morris's  method  is  as  follows : 

Excepting  on  the  face,  Morris  prepares  the  field  of  operation  with 
a  germicidal  depilatory,  and  no  other  special  preparation.  This  is  ap- 
plied five  minutes  or  so  before  the  operation.  There  are  two  depila- 
tories which  are  quite  effective:  Foral,  imported  from  Germany,  con- 
sisting of  the  sulfids  and  oxids  of  calcium  and  zinc ;  and  sulfur  starch, 
consisting  of  the  sulfids  of  calcium,  sodium,  barium,  and  zinc.  The 
former  preparation,  being  a  powder,  is  mixed  with  a  little  water  and 
applied  directly  to  the  parts.  After  three  or  four  minutes  it  is  removed 
by  a  soft  piece  of  gauze  wet  with  sterile  water.  The  sulfur  starch 
is  all  ready  to  apply,  and  for  that  reason  it  is  chosen  by  his  nurses. 
He  has  discarded  the  old  or  more  elaborate  preparation  for  operation. 
Both  the  above  preparations  being  powerful  germicides,  the  field  of 


1 6  POSTOPERATIVE    TREATMENT. 

operation  can  be  prepared  thoroughly  and  rapidly  after  the  patient  is 
on  the  table  and  under  ether. 


FINAL  CONSIDERATIONS. 

That  depilation  is  preferable  to  shaving,  especially  for  women,  ad- 
mits of  little  argument.  The  author  has  been  using  the  method  now 
advocated  by  Morris  for  several  months  with  such  satisfaction  that 
his  nurses  would  not  like  to  go  back  to  the  old  method  of  shaving 
and  other  elaborate  preparations  for  operation. 

The  depilatory  we  prefer  is  made  after  the  following  formula: 

Crystallized  sodium  sulfid, oiij 

Unslacked  lime  (fresh), , 3x 

Pulverized  starch, 3xj. 

Reduce  each  separately  to  a  fine  powder.  Mix  and  keep  dry  in  a 
well-stoppered  bottle.  When  required  for  use,  by  the  addition  of  a 
little  water  a  paste  is  formed,  which  is  spread  upon  the  parts  about  | 
inch  thick,  by  means  of  a  spatula  or  thin-bladed  knife.  After  waiting 
four  minutes  the  parts  are  flushed  with  sterile  water,  after  which,  in  lap- 
arotomies, we  use  a  solution  of  corrosive  sublimate  followed  by  alcohol. 

Solutions  to  be  Used  in  the  Peritoneal  Cavity. — Dr.  Joseph 
Price,  of  Philadelphia,  says:  "Early  in  the  history  of  the  surgery  of  in- 
fectious or  septic  or  suppurative  forms  of  peritonitis  a  variety  of  solu- 
tions— boracic  acid,  carbolic  acid,  mercuric  chlorid,  hydrogen  dioxid, 
oxygen,  etc. — were  employed  within  the  peritoneal  cavity.  Most  of 
these  have  gone  entirely  out  of  use.  Hot  tap-water  or  distilled  water 
gives  the  best  results.  Lawson  Tait  used  hot  tap-water.  I  employed 
for  a  long  .time  distilled  water,  but  this  was  found  inconvenient  and  ex- 
pensive, and  now  I  am  content  with  hot  tap-water.  Hot  salt  solution 
has  been  quite  generally  adopted,  but  in  my  opinion  its  employment  in 
large  quantities  in  the  peritoneal  cavity  does  not  give  as  good  results  as 
does  the  use  of  boiled  water.  In  abdominal  work  surgeons  are  now  not 
doing  so  many  complete  and  heroic  operations  as  formerly.  In  too 
many  instances  they  are  practising  puncturing,  or  incision  and  drain- 
age, and  are  not  removing  the  pathologic  specimens;  in  short,  they  are 
not  doing  the  complete  and  thorough  abdominal  surgery  that  they  did 
a  few  years  ago ;  hence  the  employment  of  salt  solution  gives  fairly  good 
results,  but  it  is  still  inferior  to  boiled  water. 

"  Formerly  it  was  the  rule  to  free  adhesions  when  not  too  far  advanced 


PREPARATION    OF    FIELD    OF    OPERATION.  1 7 

or  when  freeing  could  be  done  without  injury  to  the  bowel,  and  to  seek 
for  cheesy  foci  and  cleanse  them,  using  iodoform  and  drainage.  Then 
better  results  were  obtained  than  in  the  more  recent  practice  of  aspira- 
tion, simple  incision,  and  drainage.  But  in  conditions  requiring  the 
more  heroic  operations,  such  as  perforation  from  tuberculosis,  typhoid 
ulcer,  duodenal  or  gastric  ulcer,  ruptured  gallbladder,  or  leaking  hepatic 
abscess,  sterilized  water  does  the  cleansing  without  favoring  irritation 
of  the  bowel  peritoneum  and  consequent  adhesions. 

"  Postoperative  intestinal  obstruction  is  now  more  common,  follow- 
ing douches  or  irrigation  with  hot  salt  solution.  The  hot  salt  solution 
appears  to  be  really  too  good — it  favors  arrest  of  infection  or  sepsis,  but 
the  irritative  action  causes  healthy  adhesions  between  various  parts 
of  the  bowel.  I  have  had  to  reopen  three  patients  some  days  after  the 
primary  operation,  at  which  time  salt  solution  irrigation  was  employed, 
and  which  seemed  to  be  the  whole  cause  for  the  intestinal  obstruction. 
The  patients  were  apparently  doing  well  when  suddenly  obstruction 
developed.  It  is  interesting  and  pleasing  to  note  that  about  all  such 
reopened  patients  recover.  I  have  noted  recently  that  a  few  operators 
have  reported  having  to  reopen  patients  a  second  and  third  time,  and 
yet  they  still  favor  irrigating  with  salt  solution." 

As  to  Drainage. — Dr.  Joseph  Price  says  that  "the  confidence  of  the 
profession  is  beautifully  illustrated,  by  multiple  openings  fore  and  aft, 
when  the  operator  finds  infectious  foci,  abscesses  in  the  region  of  the 
gallbladder  or  liver,  neglected  perforations,  and  perforative  conditions; 
in  short,  in  those  situations  in  which  mild-mannered,  ecclesiastical 
surgeons  have  permitted  the  'pathologic  fluids  to  gravitate  to  a  safe 
place  in  the  peritoneal  cavity.' 

"Some  good  surgeons  employ  iodoform  gauze  in  pelvic  and  abdom- 
inal work.  It  is  in  puerperal  lymphangitis,  as  a  pelvic  drainage  or 
pack,  that  it  should  be  used.  Prior,  who  did  the  best  work  along  this 
line,  got  almost  specific  results  from  its  employment. 

"Sterilized  surgical  gauze  is  the  most  valuable  drain  or  dressing  ever 
given  to  surgery.  Some  surgeons  do  a  drain  operation  by  using 
it  throughout  the  operation  to  dry  the  surgical  field.  The  same  sur- 
geons object  to  drains  and  only  employ  such  methods  occasionally,  where 
local  conditions  are  filthy  and  necrotic,  and  where  they  wish  to  quaran- 
tine local  points  of  infection.  In  sterile  gauze  they  have  just  what  they 
need — gauze  to  gill-net  the  germs. 

"  Gauze  also  compensates  for  incomplete  and  imperfect  methods  in 
3 


IS  POSTOPERATIVE    TREATMENT. 

operations  for  resection  and  anastomosis,  operations  about  the  gall- 
bladder, for  gastric  and  duodenal  ulcers,  and  in  pancreatic  and  hepatic 
surgery.  In  such  situations  sterile  gauze  cofferdams  offer  admirable 
protection,  and  they  favor  results  which  as  yet  cannot  be  attained  by 
other  known  means.  The  reports  of  splendid  work  being  done  through- 
out the  country  beautifully  demonstrate  the  correctness  of  the  above 
statements. 

"Patients  suffering  from  gangrenous,  bad-smelling,  septic  conditions 
about  the  head  of  the  cecum  are  nearly  all  saved  by  the  'open  method 
of  treatment.'  A  few  years  ago  they  were  almost  all  lost.  A  few  years 
ago  the  best  surgeons  in  this  country  admitted  on  public  stages  that 
they  could  not  save  patients  suffering  from  dirty  and  infectious  perito- 
neal cavities.  In  recent  discussions  they  have  admitted  that  they  have 
saved  fifteen  and  sixteen  consecutive  cases  of  perforating  forms  of  dis- 
ease, with  every  known  variety  of  germ  infection.  This  all  speaks  well 
for  a  good-sized  opening  in  the  peritoneal  cavity,  a  wet  or  dry  toilet,  a 
gauze  pack,  single  or  multiple  drains,  or  no  drains  at  all." 


CHAPTER  II. 

POSTOPERATIVE  WOUND  SUTURE,  DRAINAGE, 
AND  DRESSINGS. 


Plate  I. 


CHAPTER  II. 

POSTOPERATIVE  WOUND  SUTURE,   DRAINAGE,   AND 

DRESSINGS. 

Postoperative  Wound  Suture.— Before  closing  the  incision  of  any 
ordinary  wound  all  oozing  points  should  be  carefully  checked,  either 
by  means  of  hot  saline  solution  or  ligated  with  fine  catgut,  and  all  hang- 
ing, ragged,  or  fatty  tissue,  liable  to  necrosis,  should  be  cut  away.  If 
the  incision  is  to  be  completely  closed,  the  surgeon  should  endeavor 
to  bring  all  the  raw  surfaces  in  exact  apposition  with  those  of  the  op- 
posite side,  and  so  arrange  the  deep  and  superficial  layers  of  tissue  as  to 
avoid  so-called  "dead  spaces"  in  which  serum  or  blood  may  accumulate. 
For  the  buried  sutures,  catgut  is  preferable  to  any  other  material.  Many 
surgeons  make  free  use  of  silkworm-gut,  silk,  or  even  silver  wire,  but 
they  frequently  cause  postoperative  annoyance  on  account  of  their 
nonabsorption,  and  should  seldom  be  used  for  this  purpose.  The  double 
catgut  ligature  method  as  employed  by  Senn  for  all  large  arteries,  is 
preferable  to  any  other  method.  We  still  prefer  silk,  however,  as  a 
ligature  on  the  femoral  or  other  large  arteries,  but  in  no  instance  has 
secondary  hemorrhage  occurred  in  any  of  the  lesser  arteries  in  which 
this  double  ligature  method  has  been  employed.  In  closing  abdominal 
incisions  the  peritoneal  surfaces  should  first  be  united  by  a  continuous 
catgut  suture,  after  which  it  is  our  custom,  in  order  to  avoid  hernia,  to 
insert  a  row  of  through-and-through  silkworm-gut  sutures,  including 
the  entire  thickness  of  the  abdominal  wall  and  upturned  edges  of  the 
peritoneum,  using  double-needle  sutures  and  inserting  them  from 
within  outward,  at  least  ^  inch  from  the  margin  of  the  wound,  and  f  of  an 
inch  apart.  (See  Plate  II.)  If,  now,  there  are  indications  that  tension 
will  be  unusually  great,  "stitches  of  relaxation,"  or  the  button  sutures, 
introduced  by  Lord  Lister,  may  be  employed  vidth  advantage,  though 
rarely  required.  A  needle  threaded  with  stout  silver  v^ire  is  in- 
serted through  the  skin  several  inches  from  the  edge  of  the  under- 
lined flap  at  the  outer  limit  of  the  underlining,  and  the  free  edge  of  this 
is  attached  to  a  button.  The  wire  is  then  carried  across  the  wound 
under  the  tissues,  and  the  needle  brought  out  through  the  skin  at  the 


22  POSTOPERATIVE    TREATMENT. 

corresponding  spot  on  the  opposite  side  where  the  underlining  ceases. 
The  wire  is  then  threaded  to  a  second  button,  which  is  pushed  as  far 
down  as  possible,  when  firm  traction  is  made  on  the  wire,  and  the  latter 
sutured  in  place.  . 

After  the  silkworm-gut  sutures  have  been  inserted  as  before  des- 
cribed, but  not  tied,  the  different  layers  of  tissue,  fascia,  or  muscle  are 
sewed  separately  (see  Plate  III)  with  pyoktanin  catgut,  and  special  care 
is  taken  to  prevent  these  sutures  being  drawn  too  tight  or  inserted  too 
closely  together,  for  sometimes  even  slight  tension  will  produce  necrotic 
tissue,  and  later  suppuration  from  pressure  of  ligatures  alone. 

Lastly,  the  silkworm-gut  sutures  are  carefully  tied,  and  the  gaping 
skin  edges  are  closed  by  a  continuous  buttonhole  or  blanket  suture  of 
fine  horsehair.     (See  Plate  IV.) 

The  silkworm-gut  sutures  hold  all  the  deeper  parts  as  well  as  the 
adipose  tissue  firmly  together,  while  the  horsehair  sutures  carefully 
approximate  the  skin  edges.  A  small  strip  of  iodoform  gauze,  one  or 
two  layers,  is  now  fixed  upon  one  side  of  the  wound  with  collodion, 
and  when  it  is  dry  the  skin  on  the  other  side  is  pressed  inward  toward 
the  line  of  incision,  and  the  free  end  of  the  gauze  strip  is  fastened  with 
collodion.  The  incision  is  now  ready  for  the  external  dressings.  The 
closure  of  the  skin  edges  of  abdominal  wounds  or  incisions  by  means  of  a 
continuous  subcuticular  silver  wire  or  single  strand  of  silkworm-gut,  as 
recommended  by  some  surgeons,  is  an  unnecessary  refinement  in  ab- 
dominal surgery.  Such  an  attempt  to  unite  skin  wounds  is  more  ap- 
plicable to  wounds  of  the  face,  and  even  here  it  is  better  surgery  to  unite 
the  deeper  tissue  if  necessary  with  fine  buried  catgut,  and  close  the  skin 
edges  by  means  of  sterile  zinc  oxid  adhesive  strips.  By  this  means  the 
epithelial  edges  are  closely  approximated  and  stitch  marks  are  abso- 
lutely avoided,  so  that  only  a  very  delicate  linear  scar  is  left,  which 
after  a  few  months  becomes  quite  unnoticeable. 

Irrigation  of  Wound  During  Operation. — In  all  aseptic  opera- 
tions irrigation  of  the  wound  or  douching  the  wound  from  time  to  time 
has  long  been  abandoned  except  by  English  surgeons.  For  the  removal 
of  blood-clots,  to  prevent  oozing,  or  when,  for  any  reason,  irrigation  of 
the  wound  before  closing  may  seem  required,  careful  sponging  with  hot 
normal  salt  solution  is  all  that  is  required,  and  preferable  to  lotions  of 
carbolic  acid  or  mercuric  chlorid.  Ochsner's  idea  of  keeping  the 
wound  as  dry  as  possible  is  commendable,  and  should  be  strictly  adhered 
to  when  possible.     In  operations  under  septic  difficulties,  when  a  cavity 


FOLATE 


Plate  II. — Closure  of  Median  Abdominal  Incision. 
The  illustration  is  intended  to  show  the  peritoneum  closed  by  a  continuous 
catgut  suture.     The  deep  silkworm-gut  sutures  are  next  inserted  from  within  out, 
extending  through  all  the  tissues,  including  the  upturned  edges  of  the  peritoneum, 
but  are  not  tied  until  the  final  closure  of  the  incision. 


PI.ATH   III. 


Plate  III  shows  Complete  Closure  of  the  Transversalis  Fascia, 
Connective  Tissue,  and  Rectus  Muscles  by  Interrupted  Buried  Cat- 
gut Sutures. 


Platf  IV. 


Plate  IV  Illustrates  the  Final  Closure  of  the  Incision. 

The  silkworm-gut    sutures  are  first   carefully  tied,  after  which  the  skin  edges  are 

carefully  closed  by  a  continuous  buttonhole  stitch  of  fine  horsehair. 


POSTOPERATIVE   WOUND   SUTURE,  DRAINAGE,    AND   DRESSINGS.        29 

contains  pus  or  blood,  it  is  frequently  important  to  irrigate  thoroughly, 
but  very  gently,  at  the  time  of  operation,  with  either  hot  normal  salt 
solution,  1 :  40  to  i :  20  carbolic  acid  solution,  or  weak  sublimate  solu- 
tion of  1 :  4000  or  1 :  3000,  if  for  any  reason  it  is  deemed  preferable. 

Drainage. — Theoretically,  a  perfectly  aseptic  wound  may  be  closed 
completely  without  drainage  of  any  kind,  and  this  practice  may,  in  many 
instances,  be  followed  by  complete  success.  It  can  be  accomplished 
uniformly,  however,  only  at  the  expense  of  a  large  amount  of  time  de- 
voted to  the  permanent  checking  of  all  hemorrhage,  however  slight, 
and  by  very  complete  and  time-consuming  attention  to  the  obliteration 
of  all  dead  spaces.     (Warren.) 

All  incised  tissues  exude  a  certain  amount  of  serum,  and  there  are 
few  wounds,  no  matter  how  carefully  attended  to,  which  are  not  followed 
by  more  or  less  subcutaneous  blood  oozing.  In  a  small  proportion  of 
cases  at  the  time  of  closure  the  wound  may  seem  to  be  absolutely  free 
from  bleeding,  but  one  or  more  vessels  will,  after  closure,  permit  some 
hemorrhage  into  the  tissues.  The  passing  of  pure  serum  or  blood  into 
the  cellular  spaces  of  a  wound  is  certainly  an  invitation  to  bacterial  de- 
velopment, which  in  a  perfectly  empty  wound  would  not  take  place. 
Carefully  applied  drainage,  in  one  form  or  other,  provides  against  the 
accumulation  of  serum  or  accidental  bleeding  into  the  tissues  and  re- 
duces to  a  minimum  the  chances  of  infection.  Drainage,  therefore, 
should  be  applied  always  to  wounds,  even  in  those  which  presumably 
are  aseptic,  in  order  to  remove  any  possible  blood  exudation.  In  aseptic 
wounds  very  small  pieces  of  gauze  will  answer  the  purpose  above  men- 
tioned, and  may  be  removed  within  a  few  hours,  or  at  the  first  convenient 
opportunity.  This  temporary  drainage  material  should  be  removed, 
as  a  rule,  within  twenty-four  hours,  or  not  later  than  forty-eight  hours, 
following  the  operation.  All  superficial  aseptic  wounds,  as  well  as  large 
and  deep  ones,  may  be  perfectly  drained  if  the  surgeon  introduces  at  one 
or  two  points  a  narrow  strip  of  guttapercha,  which  should  pass  from  the 
surface  to  the  deepest  portion  of  the  wound  that  requires  emptying. 
Such  strips  can  be  readily  placed  by  means  of  a  probe  before  closure  of 
the  wound.  They  should  not  be  more  than  J  to  J  inch  in  wddth,  and 
should  project  above  the  surface  about  one  inch.  Serum  will  find  its 
way  out  by  the  side  of  them.  These  strips  of  guttapercha  never  leave 
a  prolonged  sinus,  even  when  left  in  place  for  some  time,  and  the  wounds 
to  which  they  are  applied  heal  with  great  rapidity.  (Excerpt  from  "In- 
ternational Text-book  of  Surgery,"  vol.  i.) 


30  POSTOPERATIVE    TREATMENT. 

Of  the  various  forms  of  drainage,  india-rubber  tubing  is  usually 
the  most  convenient ;  but,  instead  of  this,  tubes  may  be  made  of  absorb- 
able bone,  glass,  or  metal.  Soft-rubber  tubes  should  always  be  given 
the  preference  when  there  is  little  liability  to  compression  of  the  tube. 
When  compression  is  liable  to  occur,  glass  is  the  most  suitable  material, 
especially  in  pelvic  and  abdominal  cases.  In  the  ordinary  septic 
cases  requiring  drainage,  in  pus-cavities,  etc.,  or  in  severe  collapsible 
wounds,  such  as  are  formed  by  coils  of  intestines,  gauze  drainage,  or, 
preferably,  gauze  rolled  in  rubber  tissue  cloth,  is  occasionally  of  great 
value  especially  when  capillary  drainage  is  desirable.  It  is  used,  how- 
ever, only  after  septic  operations,  or  in  those  which,  from  their  nature, 
are  liable  to  become  septic.  All  septic  wounds  should  be  packed 
carefully  in  order  that  the  gauze  surface  may  lie  in  contact  with  every 
portion  of  the  wound,  so  that  all  liquid  may  be  drained  off  in  the  outer 
dressings.  The  external  opening  must  invariably  be  wide  and  free. 
The  drainage-tube,  as  a  rule,  may  be  removed  after  the  first  forty-eight 
hours,  unless  specially  contraindicated  by  a  continuance  of  the  discharge. 
A  good  plan  is  to  pass  a  stitch  through  the  skin  on  each  side  of  the  tube, 
allowing  it  to  remain  untied  until  after  the  tube  is  removed.  This  will 
bring  the  parts  in  better  apposition  later.  When  positive  that  there  will 
be  little  or  no  oozing  and  the  wound  is  strictly  aseptic,  we  frequently  place 
one  or  two  layers  or  small  strips  of  iodoform  gauze  over,  covering  the 
entire  length  of  the  incision,  and  seal  this  with  collodion.  If  a  large 
cavity  in  the  abdomen  has  been  plugged  by  the  use  of  medicated  gauze, 
four  to  six  days  should  elapse,  or  even  longer,  before  attempting  its  re- 
moval; and  when  the  gauze  is  being  removed,  it  should  be  wet  from 
time  to  time  with  hydrogen  dioxid,  which  renders  it  antiseptic  and 
permits  it  to  be  more  easily  and  less  painfully  removed. 

This  does  not  apply  to  cases  of  acute  necrosis  of  bone.  When  a 
bone  cavity  has  been  packed  with  gauze,  the  packing  should  be  removed 
in  twenty- four  to  forty-eight  hours.  As  this  is  frequently  very  painful, 
an  anesthetic  may  have  to  be  employed. 

Dressings. — Essentials  requisite  for  good  w^ound-dressings  are 
that  they  shall  be  absorbent,  i.  e.,  favor  drying  which  interferes  with 
germ-growth,  and  that  they  shall  contain  germicidal  substances  pre- 
venting infection  of  the  discharges,  which  in  turn  may  reach  the  wound. 
Both  of  these  properties  render  frequent  dressing  unnecessary,  thus  giving 
rest  to  the  wound.  Many  kinds  of  antiseptic  gauzes  are  used — iodo- 
form, carbolated,  sublimated,  or  borated  gauze  fulfil  all  indications. 


POSTOPERATIVE   WOUND    SUTURE,   DRAINAGE,    AND   DRESSINGS.      3 1 

Kocher,  however,  prefers  xeroform,  others  prefer  nickel,  formaldehycl, 
mercury  bicyanid,  etc.  "  Sterilized  iodoform  gauze  5  percent,  the 
strength  now  ordinarily  used,  promotes  drying  of  the  secretions,  and 
if  sepsis  occurs,  will  help  to  destroy  the  resultant  ptomains."  (Den- 
nis.) Carbolized  gauze  of  the  strength  of  2  percent,  sublimate  gauze 
of  1 :  2000,  or  plain  sterilized  gauze  may  be  used,  and  should  be  placed 
loosely  over  the  entire  wound;  over  this  a  layer  of  sterilized  absorbent 
cotton,  wool,  oakum,  etc.,  held  snugly  but  comfortably  in  place 
by  properly  applied  bandages,  tends  toward  maintaining  rest  of  the 
parts,  promoting  drainage,  and  relieving  the  strain  upon  the  stitches. 


CHAPTER  HI. 
POSTOPERATIVE  COMPLICATIONS. 


CHAPTER  III. 
POSTOPERATIVE   COMPLICATIONS. 

Postoperative  High  Temperature. — Systemic  reaction  follows  as 
a  natural  consequence  all  major  operations,  aseptic  or  otherwise.  A 
few  hours  after  the  patient  has  recovered  from  the  effects  of  the  anes- 
thetic there  is  always  more  or  less  elevation  of  temperature.  The  exact 
cause  of  this  transitory  fever  has  not  been  fully  determined.  It  differs 
materially  from  surgical  fever,  has  no  relation  to  infection  when  moder- 
ate in  degree,  and  hence  should  cause  little  anxiety  to  the  attending  sur- 
geon. This  elevation  of  temperature  is  termed  by  Volkmann  "aseptic 
wound  fever  " ;  by  von  Bergmann,  " fermentative  fever  " ;  by  Billroth,  "re- 
sorption fever,"  or  "after-fever";  and  by  more  recent  surgical  writers, 
"simple  traumatic  or  primary  fever."  The  term  "systemic  reaction" 
seems  to  me  more  suggestive  of  the  exact  condition  than  any  of  the  names 
given,  however  complicated  the  pathologic  conditions  accounting  for 
the  same. 

Symptoms. — This  form  of  postoperative  fever  in  aseptic  cases  rarely 
lasts  more  than  forty-eight  to  sixty  hours,  and  seldom  exceeds  102°  or 
103°  F.  The  rise  of  temperature  is  gradual,  without  rigor  or  other  in- 
dications of  infection.  The  pulse  usually  increases  in  proportion  with 
the  rise  in  temperature,  and  when  the  reaction  is  over,  the  temperature 
and  pulse  become  normal  or  nearly  so,  and  thus  remain  throughout 
convalescence. 

Treatment. — Postoperative  or  reactionary  fever  requires  very  little 
treatment.  One  dram  of  the  fluid  extract  of  couch-grass  in  one  or  two 
ounces  of  hot  water,  with  15  to  20  drops  of  sweet  spirits  of  niter 
three  or  four  times  a  day,  will  tend  to  allay  thirst  and  increase  diuresis 
and  diaphoresis. 

Postoperative  Diarrhea. — Postoperative  diarrhea  is  either  the 
result  of  indiscretion  in  diet  or  an  indication  of  septic  infection.  If  due 
to  the  former,  a  laxative  of  castor  oil  followed  by  bismuth  subgallate 
is  ordinarily  sufficient  to  overcome  the  trouble.  If,  however,  the  diar- 
rhea is  the  result  of  septic  infection,  more  active  measures  are  necessar}\ 

35 


36  POSTOPERATIVE    TREATMENT. 

All  pus-cavities,  wherever  situated,  must  be  drained,  and  all  other  means 
to  overcome  sepsis  must  be  immediately  resorted  to.  In  the  adult,  15 
grains  of  beta-naphthol  bismuth  should  be  administered  in  capsules  every 
four  hours,  or,  if  a  child,  large  doses  of  bismuth  subnitrate  (10  to  20 
grains)  with  tincture  of  geranium  are  preferable.  If  the  temperature 
is  persistent  and  high,  subcutaneous  injection  of  antistreptococcic  serum 
is  often  of  great  value. 

Postoperative  Infection. — -It  is  not  within  the  province  of  this 
work  to  discuss  surgical  bacteria,  nor  the  form  and  character  of  the 
various  infective  microorganisms  which  create  postoperative  or  surgical 
fever.  Clinically,  it  is  frequently  difficult  for  even  the  expert  to  distin- 
guish between  the  various  forms  of  septic  infection  or  intoxication ;  there- 
fore it  would  appear  impracticable  to  attempt  to  draw  a  sharp  line  be- 
tween septicemia,  pyemia,  and  other  forms  of  septic  infection.  Neither 
theory  nor  practice  justifies  such  a  distinction,  since  the  pathogenic 
organisms  are  the  same  in  each  of  these  conditions,  the  morbid  anatomic 
changes  vary  more  in  degree  than  in  kind,  and  the  clinical  signs  do 
not  enable  us  to  distinguish  unerringly  between  them.  This  inability 
to  separate  these  forms  of  infection  is  frequently  due  to  the  fact  that 
typical  cases  are  seldom  seen.  The  type  usually  found  is  of  a  mixed 
character,  and  often  obscured  by  other  disturbances  which  prevent 
one  not  an  expert  from  recognizing  the  exact  character  of  the  systemic 
invasion.  Pyemia  no  longer  means,  as  its  etymology  implies,  pus  in 
the  blood.  By  pyemia  we  now  mean  a  form  of  blood-poisoning  by 
pyogenic  organisms,  in  which  living  bacteria  are  transported  by  the 
blood  to  distant  tissues,  where  they  multiply  and  produce  abscesses; 
so  that  in  pyemia  the  production  of  multiple  abscesses  is  the  typical 
pathologic  phenomenon,  just  as  in  septicemia  the  dominant  feature 
is  the  systemic  intoxication  with  living  bacteria  in  the  blood.  "  Septi- 
copyemia "  is  a  clinical  term  used  to  convey  the  impression  that  the 
symptoms  of  sepsis  are  as  well  marked  as  those  of  pyemia.  (Warren- 
Gould.) 

I  shall,  therefore,  describe  under  this  one  heading  of  "postopera- 
tive infection"  the  ordinary  symptoms  of  systemic  infection  or  blood- 
poisoning  as  commonly  seen  and  recognized  by  the  terms  septicemia, 
pyemia,  and  septicopyemia  so  far  as  they  relate  to  or  follow  surgical 
operations. 

Symptoms. — The  symptoms  of  septicemia  differ  in  intensity  with  the 
extent  and  character  of  the  infection.     The  symptoms  may  be  very  mild 


POSTOPERATIVE    COMPLICA'I  IONS.  37 

and  last  Ijut  a  few  hours;  on  the  other  hand,  if  the  seat  of  su]>|juration, 
from  improper  drainage  or  after  supposedly  aseptic  operations,  necrosis  of 
tissue  with  suppuration  from  stitch-pressure  makes  its  appearance  as 
a  result  of  improperly  sterilized  articles  used  during  the  operation,  the 
symptoms  may  be  so  pronounced  as  to  endanger  the  life  of  the  patient. 
Again,  if  extensive  surfaces  capable  of  rapid  absorption  are  suddenly 
flooded  with  infected  fluids,  toxemia  follows  rapidly,  and  death  may 
quickly  follow.  For  example,  in  operations  for  appendicular  abscess, 
or  upon  a  gallbladder  containing  pus,  which  is  accidentally  incised 
or  is  ruptured  into  the  abdominal  cavity,  death  frequently  follows  within 
a  few  hours.  The  ordinary  symptoms  of  infection  usually  appear  within 
from  five  to  six  days  following  operation.  The  sudden  rise  of  tem- 
perature to  103°,  104°,  or  105°  F.,  preceded  by  a  slight  chill,  should 
always  be  sufiicient  notice  to  the  attending  surgeon  of  infection  and  im- 
pending danger,  and  it  demands  prompt  attention.  These  symptoms, 
if  neglected,  become  more  and  more  pronounced ;  the  patient  feels  hot, 
or  there  is  a  condition  of  alternating  heat  with  chilly  sensations.  The 
skin,  lips,  and  mouth  are  dry;  urine  becomes  scanty  and  of  a  high  color; 
the  pulse  becomes  weak  and  rapid,  and  there  is  always  more  or  less  gen- 
eral disturbance.  The  patient  becomes  restless,  the  face  has  a  flushed, 
anxious  look,  the  temperature  is  always  higher  at  night  with  morning  ex- 
acerbations, sleep  is  troubled  and  unrestful,  and  there  is  usually  delirium. 
The  symptoms,  unless  relieved,  assume  more  and  more  a  typhoid  con- 
dition ;  nausea  and  vomiting,  with  profuse  diarrhea,  extreme  exhaustion, 
and  depression  of  the  vital  forces,  are  now  prominent  symptoms.  The 
tongue  becomes  dry  and  brown,  and  even  cracked;  the  breath  is  often 
foul;  the  perspiration  from  the  body  of  the  patient  becomes  sour,  pun- 
gent, and  of  a  disagreeable  odor;  delirium  is  well  marked,  and  the  pa- 
tient passes  into  coma.  Movements  from  the  bowels  and  kidneys  be- 
come involuntary,  the  temperature  continues  to  rise,  pulse  becomes 
more  and  more  rapid,  and  death  is  ushered  in  by  failure  of  respiration. 
This  slow  form  of  septicemia  may  continue  for  several  months,  as 
every  surgeon  of  experience  can  testify.  Marasmus  may  increase  to 
such  an  extent  that  the  patient  is  reduced  to  a  pitiful  degree  of  physical 
debihty,  from  pent-up  pus.  Should  living  pyogenic  organisms,  by  means 
of  the  pus,  enter  the  blood,  and  be  thus  carried  to  various  parts  of  the 
system,  we  will  have  the  condition  known  as  pyemia,  which  difi'ers  from 
septicemia  only  in  the  formation  of  metastatic  deposits.  The  t^-pical 
cases  of  pyemia  are  easily  distinguished  clinically  from  septicemia  by 


38  POSTOPERATIVE    TREATMENT. 

the  finding  of  these  secondary  abscesses;  and,  in  addition  to  the 
symptoms' already  described,  we  have  marked  rigors,  followed  by  profuse 
sweating.  The  occurrence  of  these  symptoms  announces  to  the  attend- 
ing surgeon  that  the  elements  of  pyemia  have  been  added  to  those  of 
septicemia.  The  surgeon  must  ever  bear  in  mind  the  important  fact 
that,  no  matter  what  the  character,  extent,  or  locality  of  the  operation 
or  whether  it  be  five  days,  ten  days,  or  two  wxeks  following  the  operation, 
a  sudden  rise  of  temperature  to  102°  or  104°  F.,  with  or  without  a  severe 
chill,  and  corresponding  disturbance  of  the  circulatory  system,  always 
denotes  infection  and  demands  prompt  interference.  The  condition 
requires  the  immediate  adoption  of  drainage,  or  if  drainage  has  been 
eniployed,  it  requires  that  it  should  now  be  more  thorough.  These 
signs  are  positive,  hence  delay  is  inexcusable.  The  temperature-record 
is  nearly  always  characteristic  of  septicemia.  The  morning  tempera- 
ture is  lower  and  rises  to  the  maximum  only  at  night.  In  pyemia, 
rigors,  often  severe,  followed  usually  by  profuse  sweating,  are  the  out- 
ward manifestations.  The  nervous  system  is  at  times  stimulated  by 
sepsis,  so  that  the  patient  does  not  realize  his  own  jeopardy.  (Warren, 
"Surgical  Pathology.")  But  usually,  especially  after  the  first  few 
days,  the  patient  is  restless  or  inclined  to  be  in  a  state  of  stupor. 

Treatment. — In  all  cases  of  postoperative  infection,  septicemia, 
pyemia,  etc.,  an  attempt  should  be  made  to  ascertain  the  source  of  in- 
fection, and  all  efforts  directed  not  only  toward  the  support  of  the  patient, 
but  the  elimination  of  the  toxins  and  microorganisms  from  the  body. 
The  patient's  bowels  must  move  properly,  the  kidneys  act  freely,  and 
no  intestinal  putrefaction  should  be  allowed  to  remain.  It  is  often  nec- 
essary to  support  the  patient's  strength  from  the  first;  hence  a  generous 
diet  should  be  given,  and  so  soon  as  the  pulse  begins  to  fail,  free  stimu- 
lation will  become  necessary.  All  wounds  should  be  opened,  and  after 
thorough  irrigation  with  an  antiseptic  solution,  drained  freely.  Anti- 
streptococcic serum  is  often  of  the  greatest  value.  A  combination  of 
quinin,  3  grains,  with  phenacetin,  5  grains,  every  three  or  four  hours, 
may  likewise  prove  of  utility.  Should  typhoid  symptoms  supervene, 
the  treatment,  as  in  all  other  exhausting  diseases,  should  be  directed  to 
the  support  of  the  patient's  strength  by  nourishing  food,  tonics,  and 
stimulants.  Antipyretics  should  usually  be  avoided,  for  the  reason  that 
they  frequently  act  as  cardiac  depressants ;  excessive  temperature  should 
be  overcome  by  cool  sponge-bathing.  According  to  Billroth,  a  most 
important  medicinal  agent  to  combat  septic  infection  is  alcohol.     It  is 


POSTOPERATIVE    COMPLICATIONS.  39 

borne  by  patients  in  large  closes  and  appears  to  exercise  a  favorable  in- 
fluence upon  the  course  of  the  malady.  It  should  be  administered  in 
the  form  of  brandy  or  whisky.  In  egg-nog,  egg-flip,  etc.,  we  have  a 
ready  means  of  combining  this  agent  with  food.  With  peptonized  milk 
and  eggs,  the  alcohol  may  be  introduced  in  clysters  when  the  stomach 
fails.  (Warren.)  Digitalis  is  reserved  until  the  pulse  weakens,  but 
strychnin,  pushed  almost  if  not  quite  to  the  physiologic  limit,  now  enjoys 
a  wide  and  apparently  well-deserved  popularity  as  a  tonic  stimulant. 
Feeding  is  just  as  important  here  as  in  typhoid  fever,  and  it  is  the  atten- 
dant's duty  to  see  that  a  regular  plan  of  feeding  is  arranged  and  adhered 
to.  When  the  patient  can  no  longer  digest  his  food,  it  must  be  digested 
before  it  is  administered.  (For  further  information  upon  this  subject 
the  reader  is  referred  to  the  chapter  on  "Treatment  of  Septic 
Wounds.") 

Postoperative  Hemorrhage. — Postoperative  hemorrhage  is  some- 
times a  matter  of  great  annoyance,  especially  after  amputations  or  oper- 
ations upon  pus-cavities,  bones,  ribs,  the  tongue,  etc.  The  slipping 
of  ligatures,  faulty  technic,  neglect  to  ligate  the  smaller  arteries  or  fail- 
ure to  stop  all  oozing  at  the  time  of  operation,  may,  immediately  follow- 
ing systemic  reaction,  lead  to  accidental  or  recurrent  hemorrhage.  This 
form  of  hemorrhage  is  manifest  usually  in  from  two  to  four  hours  fol- 
lowing operations,  the  dressings  and  bandages  becoming  suddenly  satu- 
rated with  blood.  The  hemorrhage  may  be  caused  by  capillary  oozing, 
or  may  be  the  direct  result  of  constitutional  idiosyncrasy  or  disease,  such 
as  hemophilia,  jaundice,  or  leukocythemia,  etc.  If  the  bleeding  is  from 
an  artery,  however  small,  a  large  hematoma  may  form  and  produce 
distention  of  the  wound.  In  any  case,  all  the  dressings  should  be  imme- 
diately removed,  the  source  of  the  hemorrhage  ascertained,  and  the  clot, 
if  present,  removed.  If  the  bleeding  is  from  a  vein,  all  constriction 
above  the  wound  must  be  removed  before  the  hemorrhage  will  cease. 
If  the  hemorrhage  is  not  profuse,  new  dressings  should  be  applied  and 
pressure  made  by  means  of  a  snugly  applied  bandage.  This  will  usually 
suffice  to  arrest  all  bleeding,  especially  if  venous  or  capillary.  When 
the  bleeding  point  is  deeply  seated  and  when  it  is  not  desired  to  open 
up  the  wound,  pressure  may  be  applied  in  the  form  of  a  compress  apphed 
directly  over  the  surface  of  the  wound.  If  this  does  not  suflice  to  con- 
trol the  hemorrhage,  and  there  is  evidence  of  exhaustion,  the  patient 
must  be  anesthetized  immediately,  the  wound  laid  open  in  its  entirety, 
and  the  bleeding  vessel  secured. 


40  POSTOPERATIVE    TREATMENT. 

Bleeding  from  Bones. — ^^In  case  of  bleeding  from  bones,  Horsley 
has  introduced  an  aseptic  wax  which  can  be  applied  by  firm  pressure 
over  the  bleeding  point  so  as  to  close  the  opening  in  the  bone  from  which 
the  blood  comes.  The  composition  of  this  wax  is :  Beeswax,  seven  parts ; 
almond  oil,  one  part;  salicylic  acid,  one  part.  When  not  in  use,  the  wax 
is  kept  in  carbolic  solution,  i :  20.  When  it  is  required  for  use,  a  small 
piece  is  pinched  off,  softened  by  rolling  between  the  fingers,  which  of 
course  should  be  aseptic,  and  then  placed  into  the  part  of  the  bone  from 
which  the  blood  is  coming.  The  wax  gives  rise  to  no  trouble  in  healing 
of  the  wound.     (Cheyne.) 

Hemophilia. — Bertrand  and  Pilcher  contend  that  the  danger  of 
capital  operations  is  greatly  overrated  in  this  class  of  cases,  because  the 
larger  vessels  bleed  no  more  than  in  ordinary  patients.  Our  experience 
is  limited  to  but  two  cases  of  congenital  bleeders,  and  if  these  are  a  fair 
criterion,  we  would  certainly  avoid  operative  measures  unless  absolutely 
necessary ;  but  if  forced  to  do  so,  would  ligate  carefully  the  most  minute 
vessels  and  sear  the  surfaces  of  all  raw  edges  with  the  actual  cautery 
and  close  the  wound,  if  possible,  by  adhesive  strips  instead  of  using 
needles  and  sutures.  In  cases  of  hemophilia,  suprarenal  extract  given 
in  powdered  form,  5-  to  lo-grain  doses  thrice  daily,  has  of  late  been  highly 
extolled.  Calcium  chlorid  in  large  doses  occasionally  proves  efficacious, 
and  should  be  tried  if  other  styptics  fail.  Weil  uses  a  5  percent  solu- 
tion of  gelatin  as  a  local  styptic  in  these  cases  with  successful  results. 
Wright,  of  Netley,  introduced  fibrin-ferment  as  a  styptic  for  the  purpose 
of  checking  excessive  oozing  from  large  raw  surfaces.  A  piece  of  steri- 
lized lint,  sponge,  or  muslin  is  saturated  with  the  ferment  solution  and 
laid  upon  the  oozing  surface,  so  as  to  come  thoroughly  into  contact  with 
all  the  bleeding  points.  Its  action  is  to  induce  rapid  coagulation  of  the 
blood  as  it  issues  from  the  vessels;  if  these  are  small,  the  result  is 
good. 

Secondary  Hemorrhage. — Secondary  hemorrhage,  the  dread  of 
our  forefathers,  rarely  occurs  in  these  days  of  aseptic  surgery.  It  occa- 
sionally occurs  in  amputations  or  major  operations,  however,  as  a  result 
of  the  sloughing  of  arteries  in  septic  wounds,  especially  if  there  is  a  con- 
dition of  atheroma.  The  too  rapid  absorption  of  the  ligatures,  or  pos- 
sibly their  imperfect  application,  may  be  classed  as  causes  of  this  un- 
fortunate occurrence.  The  double  ligation,  with  catgut,  of  all  larger 
arteries,  one  ligature  placed  about  one-fourth  of  an  inch  proximal  to 
the  other,  materially  lessens  the  tendency  to  this  complication.     Secon- 


POSTOPERATIVE     COMPLICATIONS.  4I 

clary  hemorrhage  may  occur  at  any  time  within  from  twenty-four  hrmrs 
to  two  or  three  weeks  after  major  amputations.  About  the  twelfth  to 
the  fourteenth  day  is  the  time  when  it  may  be  most  expected.  The 
slightest  sign  of  fresh  hemorrhage  upon  the  bandages  or  dressings  should 
be  regarded  as  important,  and  requiring  immediate  examination.  If 
this  hemorrhage  is  slight,  simple  pressure  by  means  of  a  bandage  may 
suffice  for  its  control.  If,  however,  the  hemorrhage  is  profuse,  the  tour- 
niquet should  be  first  applied,  and  if  the  wound  be  open,  a  ligature 
should  be  applied  to  the  end  of  the  vessel.  In  sloughing  wounds  or  in  a 
nearly  healed  stump  it  is  often  advisable  to  ligate  the  vessel  in  continuity. 
(Warren.) 

In  secondary  hemorrhage  following  operations  upon  the  tongue, 
or  in  cavities  where  it  is  impossible  to  pass  a  ligature,  acupressure  by 
means  of  a  proper  forceps,  the  needle  of  which  passes  through  the  tissues 
so  as  to  include  the  vessel,  may  be  attempted,  or  the  wound  may  be  firmly 
packed  with  aseptic  gauze.  These  means  failing,  resort  should  be  had 
to  the  actual  cautery. 

Postoperative  Hemorrhage  after  Nasal  Operations. — Hemor- 
rhage following  nasal  operations  is  sometimes  extreme  and  depends 
upon  the  character  and  extent  of  the  operation.  In  case  spurs  spring- 
ing from  cartilaginous  bases  have  been  removed,  simply  touching  the 
denuded  area  with  a  lo  percent  solution  of  camenthol  (Bishop)  is  suf- 
ficient. The  same  treatment  will  apply  to  many  polypus  operations.  In 
cases  of  more  persistent  hemorrhage,  such  as  in  operations  on  turbinated 
bodies,  spurs  with  bony  bases,  etc.,  packing  the  cavity  is  necessary.  This 
packing  should  not  be  confounded  with  the  old-fashioned  "plugging." 
The  packing  should  be  so  introduced  as  to  prevent  hemorrhage,  w^hile 
mere  plugging  closes  the  anterior  and  posterior  nasal  openings,  per- 
mitting the  nasal  cavity  proper  and  sinuses  to  become  filled  with  blood 
if  the  hemorrhage  is  sufficient.  The  ideal  method  is  to  pack  the  entire 
field  of  operation  with  some  substance  that  will  prevent  or  check  all 
hemorrhage  without  causing  hard  coagula,  one  that  the  operator  can 
adjust  so  as  to  regulate  the  amount  of  pressure,  or  remove  part  without 
disturbing  the  remainder.  The  following  method  has  been  used  with 
satisfaction :  A  strip  of  gauze,  one-half  inch  wide  and  in  length  one  to 
two  yards,  is  folded  on  itself,  and  the  end  formed  by  the  fold  is  tied  in 
the  middle  by  a  heavy  silk  ligature.  The  gauze  should  be  saturated 
with  10  percent  camenthol  solution,  and  after  pressing  out  the  excessive 
fluid,  the  packing  is  ready  for  use.     Apply  with  a  slender  forceps  under 


42  POSTOPERATIVE    TREATMENT. 

good  illumination,  seizing  the  gauze  at  the  point  where  the  ligature  is 
attached.  '  Pass  a  portion  of  the  packing  well  back  of  the  seat  of  opera- 
tion, holding  the  ligature  at  each  end  aside  and  packing  between.  Fill  the 
nasal  cavity  as  well  above  the  bleeding  surface  as  possible.  When  no 
more  can  be  used,  clip  off  the  excessive  gauze,  grasp  both  ends  of  the 
ligature  in  one  hand,  place  a  finger  against  the  packing  to  prevent  dis- 
placement, and  make  tension  by  drawing  upon  the  ligatures  sufficiently 
to  obtain  the  pressure  desired.  Lastly,  tie  the  ligature  over  the  anterior 
or  exposed  end  of  the  packing,  by  means  of  which  direct  pressure  is  made 
upon  the  bleeding  surfaces.  The  packing  should  be  allowed  to  remain 
forty-eight  hours,  after  which  the  ligature  should  be  clipped  and  that 
portion  of  the  packing  which  comes  away  readily  should  be  removed. 
If  a  small  part  of  the  packing  is  adherent  to  the  wound,  it  should  not 
be  disturbed.  By  keeping  the  nasal  cavity  well  cleansed  with  a  mild 
antiseptic  solution,  the  remaining  gauze  will  loosen  in  twenty-four  to 
thirty-six  hours,  and  can  then  be  removed  without  causing  further 
hemorrhage. 

Postoperative  Hematemesis. — The  advent  of  hematemesis  after 
operation  is  a  serious  complication.  The  mortality  is  high.  Of  twenty- 
nine  cases  already  recorded,  69  percent  died.  The  incidence  of 
hematemesis  is  not  associated  with  any  particular  form  of  operation.  In 
the  majority  of  instances  it  has  followed  operations  relating  to  the  abdo- 
men. But,  on  the  other  hand,  Purves  has  been  informed  of  two  cases  in 
which  it  followed  amputation  through  the  thigh  and  the  removal  of  a 
neuroma  in  an  amputation  stump.  As  a  rule,  there  is  no  history  of  pre- 
vious gastric  symptoms  or  vomiting  of  blood.  Chloroform-sickness  may 
or  may  not  precede  the  hematemesis,  and  in  only  a  few  cases  can  be  held 
responsible  for  initiating  the  bleeding.  In  those  cases  in  which  vomit- 
ing after  the  anesthetic  is  present,  it  appears  more  usual  for  the  hemat- 
emesis to  come  on  gradually.  In  the  absence  of  chloroform-sickness 
one  finds  that  the  first  hematemesis  is  often  quite  sudden.  In  the  ma- 
jority of  cases  hematemesis  sets  in  within  forty-eight  hours  of  the  opera- 
tion, though  it  may  be  delayed  for  some  days.  There  may  be  only  one 
or  two  occasions  within  a  period  of  two  or  three  hours  in  which  blood 
is  vomited,  which  is  favorable;  or  the  vomiting  may  continue  at  fre- 
quent intervals  for  a  period  of  fifteen  to  twenty  hours.  In  the  latter 
instance,  as  a  rule,  there  will  be  a  fatal  termination  within  twenty-four 
hours  of  the  onset.  The  vomiting  is  generally  small  in  quantity,  though 
in  some  cases  one  to  three  pints  have  been  ejected.     It  consists,  as  a 


POSTOPERATIVE    COMPLICATIONS.  43 

rule,  of  blackish-brown  fluid,  with  a  varying  amount  of  bile  and 
of  digested  blood.  The  feature  of  these  cases  that  is  most  striking  is 
the  state  of  collapse  and  asthenia  into  which  the  patients  often  enter 
so  rapidly.  The  condition  is  often  a  perfectly  obvious  toxemia  from 
a  recognizable  septic  infection  of  the  operation  wound.  But  in  many 
cases,  and  chiefly  in  those  of  the  greatest  gravity,  one  is  at  a  loss  to  ac- 
count with  certainty  for  the  cause  of  the  depression  and  rapidly  advanc- 
ing inanition.  It  is  clear  that  all  cases  of  postoperative  hematemesis 
are  not  due  to  any  one  cause.  In  a  certain  number  of  cases  it  can  be 
attributed,  without  a  doubt,  to  gastric  ulcer  or  rupture  of  a  bloodvessel, 
when  atheroma  or  cirrhosis  of  the  liver  is  present,  and  in  such  cases  it 
is  no  doubt  precipitated  by  chloroform-sickness.  Injury  and  a  non- 
infected  embolus  from  a  ligated  omentum  may  account  for  some  cases. 
But  the  author  believes  in  those  cases  in  which  such  an  explanation 
is  not  possible — and  they  are  the  majority — that  the  origin  is  of  an 
infective  nature.     (Purves,  "Edinburgh  Med.  Jour.") 

Prognosis. — Prognosis  is  always  grave.  The  more  marked  the 
systemic  resistance,  the  greater  is  the  chance  of  recovery.  Subdued 
or  masked  infection,  with  subnormal  temperature  and  rapid  pulse,  a 
rapidly  increasing  vital  depression,  the  vomiting  tending  to  become  re- 
gurgitant, renders  prognosis  graver.  If  bilious  vomiting  appears  after 
one  or  two  paroxysms  of  vomiting  blood,  the  prognosis  is  favorable. 

Treatment. — ^The  stomach  should  be  washed  out  at  once  with  a  2 
percent  solution  of  sodium  bicarbonate,  at  a  temperature  of  iio°to  I20°F., 
until  the  fluid  returns  clear;  to  be  followed  by  a  i :  1000  solution  of  adre- 
nalin chlorid  in  normal  salt  solution.  When  collapse  is  marked,  infusion 
of  normal  saline  solution,  with  adrenalin,  into  a  vein  should  be  done 
as  well,  and  both  procedures  should  be  repeated  if  there  is  any  return 
of  hematemesis  or  collapse.  Strychnin  hypodermatically  is  of  value. 
All  patients  should  be  nourished  by  rectal  alimentation,  and  no  food 
should  be  given  by  the  mouth  until  all  symptoms  have  improved  and 
the  patient  is  in  a  normal  condition. 

Intestinal  Paresis,  or  Pseudo-ileus. — After  abdominal  section 
WT  sometimes  encounter  a  peculiar  condition,  frequently  as  unexpected 
as  inexplicable,  which  has  been  called  by  some  of  our  modern  surgeons 
"intestinal  paresis,  or  pseudo-ileus."  This  implies  a  form  of  intestinal 
obstruction  brought  about  by  a  certain  degree  of  muscular  paralysis 
of  the  intestinal  tract.  The  term  "delayed  shock"  has  also  been  used 
for  this  affection,  although  the  ordinary  symptoms  of  shock  are  seldom 


44  POSTOPERATIVE    TREATMENT. 

present.  The  cause  is  usually  attributed  to  prolonged  intestinal  ex- 
posure, but  in  our  own  experience  it  is  seldom  seen  after  most  extensive 
operations,  and  more  frequently  follows  minor  procedures,  unattended 
by  hemorrhage  or  intestinal  adhesions.  I  can  find  no  literature  on  the 
etiology  of  this  subject,  but  the  more  I  observe  these  cases,  the  more  I 
am  disposed  to  consider  them  distinctively  neurotic  in  character,  the 
abnormal  nerve-force  or  peculiar  idiosyncrasy  on  the  part  of  the  patient 
being  responsible  in  a  great  degree  for  the  condition  of  the  nervous  system 
which  permits  such  profound  exhaustion.  The  neurotic  element  may 
therefore  enfeeble  systemic  resistance  to  such  a  degree  as  to  prevent 
normal  reaction.  I  have  noticed  in  several  instances  that  lumbar  pain, 
or  pain  at  the  base  of  the  occiput,  preceded  the  local  or  abdominal  symp- 
toms. Lastly,  symptoms  limited  solely  to  the  intestinal  tract  are  rare. 
This  condition  of  ileus  is  often  confused  with  peritonitis.  It  differs 
from  other  cases  of  intestinal  obstruction  by  its  rapidly  fatal  course  if 
unrelieved. 

The  following  is  typical  of  the  condition  described  as  intestinal  ileus 
or  paresis: 

Mary  S.,  twenty-eight  years  of  age,  brunet,  medium  height,  slight  in 
build,  weight  about  io6  pounds,  unmarried,  seamstress.  Had  repeated 
attacks  of  dysmenorrhea  for  several  years,  decidedly  nervous  temperament, 
hysteric  at  times,  of  late  quite  despondent,  appetite  poor,  urine  scanty.  Op- 
eration— fixation  of  retroverted  uterus;  anesthetic — ether.  Patient  took  the 
anesthetic  very  slowly  or  tediously.  Operation  was  simple,  no  adhesions 
or  other  difficulties;  ovaries  normal  and  anterior  fixation  was  rapidly  per- 
formed. Time  of  operation,  twenty-six  minutes.  Abdominal  wound  closed 
by  the  ordinary  method.  No  normal  salt  flushing.  Patient  recovered  from 
the  anesthesia  with  very  little  nausea.  The  following  day  she  complained  of 
thirst,  but  otherwise  the  symptoms  were  normal,  except  that  the  pulse  was 
somewhat  feeble.  The  conditions  remained  the  same  until  the  morning  of  the 
second  day,  but  apparently  without  effect.  The  morning  of  the  fourth  day, 
about  an  hour  after  an  ounce  of  castor  oil  had  been  given,  she  complained 
of  severe  pain  in  the  back,  and.  shortly  following  these  symptoms  the  tym- 
panitic or  distended  condition  of  the  abdomen  was  first  noticeable.  There 
was  also  an  inclination  toward  listlessness  or  stupor.  The  temperature, 
which  had  continued  about  normal,  fell  to  about  98°  (in  the  rectum) ;  pulse 
became  feeble  and  rapid.  Attempts  to  establish  catharsis  failed,  and  lavage 
of  the  stomach  was  repeated  several  times  without  apparent  benefit,  but 
despite  every  effort  the  patient  gradually  passed  into  a  comatose  condition 


POSTOPERATIVE   COMPLICATIONS.  45 

and  died  on  the  morning  of  the  fifth  day.  At  the  autopsy  no  apparent  cause 
for  the  trouble  could  be  found.  The  abdominal  wound  had  healed  by  first 
intention. 

Symptoms. — The  characteristic  symptoms  of  this  form  of  ileus  or 
paresis  are,  therefore,  inability  to  secure  bowel  movement,  general  tym- 
panitic condition  of  the  bowels,  apparent  exhaustion  of  the  vital  forces 
with  normal  or  subnormal  temperature  and  feeble  pulse — symptoms 
usually  appearing  three  or  four  days  following  abdominal  operations. 

Treatment. — These  cases  frequently  terminate  fatally,  especially 
if  not  recognized  early.  Death  is  supposed  to  be  caused  by  changes 
in  the  central  nervous  system,  or,  according  to  some  pathologists,  is  the 
direct  result  of  toxic  effects  due  to  the  migration  of  Bacillus  coli  communis. 
Our  aim  must  be  to  establish  peristalsis  as  quickly  as  possible.  Lavage 
of  the  stomach  should  be  performed  early,  after  which  a  rectal  tube 
should  be  inserted  to  overcome  the  resistance  of  the  sphincter  ani.  High 
rectal  enemas  of  normal  salt  solution,  glycerin,  or  soap  and  water  should 
now  be  given ;  and  if  these  fail  to  give  prompt  relief,  resort  must  be  had 
to  purgatives,  both  by  oral  and  rectal  administration. 

I  rely,  first,  upon  thorough  lavage ;  second,  upon  calomel  in  one-fourth- 
grain  to  one-half-grain  doses  every  hour,  followed  by  a  purgative  of 
one  dram  of  rochelle  salts,  repeated  every  two  hours.  High  enemas  of 
one  ounce  of  magnesium  sulfate,  dissolved  in  three  ounces  of  hot  water 
to  which  one  or  two  ounces  of  glycerin  have  been  added,  should  be  given 
every  two  hours  until  eft"ective.*  In  cases  in  which  aperient  medicines 
cannot  be  given  by  the  mouth,  in  consequence  of  vomiting,  and  no  result 
has  followed  simple  enemas,  the  following  purgative  enemas  may  be 
found  of  value: 

1.  Castor  oil,  turpentine,  i  ounce  of  each  in  10  ounces  of  thin  gruel. 

2.  The  British  Pharmacopoeia  enema  terebinthinee,  containing  i 
ounce  of  turpentine  to  15  ounces  of  mucilage  of  starch.  (Both  of  these 
preparations,  however,  are  rather  strong,  and  I  usually  employ  an 
enema  of  one  pint  of  gruel  containing  one  to  two  drams  of  turpentine.) 

3.  Enema  of  magnesium  sulfate  (or  enema  catharticum,  B.  P.): 
magnesium  sulfate  i  ounce,  oHve  oil  i  ounce,  mucilage  of  starch  15 
ounces. 

*  Franklin  H.  Martin  has  called  attention  to  the  fact  that  glycerin  sometimes  acts  as 
a  violent  irritant  poison.  He  attributes  two  deaths  to  this  cause  when  the  enemas  were 
retained.  When  these  enemas  are  retained  their  expulsion  should  be  favored  bv  flush- 
ing the  bowel  with  salt  solution. 


46  POSTOPERATIVE    TREATMENT. 

4.  Enema  of  aloes  (B.  P.):  Aloes  40  grains,  potassium  carbonate 
15  grains,  mucilage  of  starch  10  ounces. 

5.  Enema  of  colocynth  contains  extract  of  colocynth  ^  dram,  soft 
soap  I  dram,  water  i  pint. 

6.  Enema  of  glycerin,  i  to  2  ounces  with  i  ounce  of  tincture  of 
asafetida  and  i  ounce  of  magnesium  sulfate,  dissolved  in  4  ounces 
of  hot  water. 

In  addition  to  the  above,  a  solution  of  pepsin  with  diluted  muriatic 
acid,  or  10-  to  15-drop  doses  of  tincture  of  nux  vomica  every  four  hours, 
may  prove  of  value  in  restoring  digestion  and  normal  peristalsis. 

Wiggin  ("Am.  Med.  Jour.,"  1892,  page  627)  beheves  that  postoper- 
ative intestinal  paresis  may  be  successfully  overcome  in  almost  all  cases  if 
the  surgeon  is  on  the  watch  for  the  early  symptoms,  and  is  prompt  in  treat- 
ment. He  dwells  upon  the  important  fact  that  the  stomach  and  bowels 
should  be  emptied  before  the  anesthetic  is  given.  If  he  has  reason  to 
believe  that  there  is  some  tendency  to  paresis,  and  if  a  proper  preparation 
of  the  stomach  was  not  possible  before  the  operation,  he  insists  that  before 
the  patient  regains  consciousness  the  stomach  shall  be  carefully  washed 
out  and  four  or  five  ounces  of  a  saturated  solution  of  magnesium  sulfate 
be  poured  through  the  stomach-tube  before  it  is  withdrawn.  If  symp- 
toms are  first  noted  some  hours  after  the  operation,  the  contents  of  the 
blue  paper  of  a  seidlitz  powder  should  be  dissolved  in  a  full  glass  of  water, 
the  contents  of  the  white  paper  scattered  upon  the  surface,  and  the  pa- 
tient directed  to  drink  while  the  effervescence  is  going  on.  The  genera- 
tion of  a  part  of  the  gas  in  the  stomach  will  help  to  overcome  the  press- 
ure of  gas  in  the  intestines.  If  the  draft  is  vomited,  a  second  dose  should 
be  given,  and  if  this  is  not  retained,  the  stomach  should  be  washed  out 
and  a  saturated  solution  of  magnesium  sulfate  introduced.  The  use 
of  a  rectal  tube  and  of  hypodermatic  administration  of  strychnin  and 
atropin  is  also  recommended,  but  the  essential  part  of  treatment  is  that 
mentioned  above.  Arndt  ("Zentralblatt  fiir  Gynakologie")  narrates  five 
cases  of  postoperative  intestinal  paresis,  in  all  of  which  the  patients  re- 
covered after  the  use  of  eserin.  The  preparation  which  the  author  uses  is 
the  salicylate  of  physostigmin,  hypodermatically  administered  in  the  dose 
of  -gig-  of  a  grain.  Usually  within  an  hour  abdominal  cramps  were  felt, 
and  soon  after  flatus  was  passed  with  a  total  disappearance  of  the  serious 
symptoms — meteorism,  shallow  and  rapid  respirations,  rapid  and  flicker- 
ing pulse,  and  the  appearance  of  collapse. 


POSTOPERATIVE     COMPLICA'IIONS.  47 

Postoperative  Lung  Complications. — Postcjpcrativc  bnjnchitis, 
bronchopneumonia,  and  lobar  pneumonia  are  rare  postoperative  occur- 
rences, and  when  they  occur,  may  usually  be  attributed  directly  to  the 
anesthetic  itself,  or  are  the  result  of  prolonged  anesthesia,  especially  when 
the  patient  has  been  subject  to  changes  of  temperature  or  drafts  during 
administration.  Crouch,  who  investigated  this  subject  at  the  St. 
Thomas  Hospital  in  London,  found  in  2400  administrations  of  ether,  ten 
cases  of  subsequent  lung  comphcations  which  were  directly  attributable 
to  the  anesthetic.  Peterson  ("Am.  Med.  Jour.,"  1892,  page  1075)  reports 
two  cases  of  postoperative  pneumonia,  three  of  pleurisy,  and  one  of  bron- 
chitis. Such  pneumonia  may  be  infectious  or  due  to  inhalation  of  irritants. 
Bronchopneumonia  is  apt  to  follow  operations  on  the  pharynx  or  larynx, 
and  the  administration  of  an  anesthetic  in  the  extremes  of  life.  Peter- 
son does  not  agree  with  Prescott  as  to  the  relative  infrequency  of  post- 
operative pneumonia.  He  uses  the  best  Squibb 's  ether,  and  takes  par- 
ticular care  to  avoid  chilling  the  patient  during  operation.  In  major 
abdominal  operations  he  modifies  the  Trendelenburg  position  by  par- 
tially elevating  the  head  of  the  table  after  the  intestines  have  been  re- 
moved and  held  from  the  pelvis  by  packs.  Metastatic  pneumonia  is 
more  apt  to  occur  after  abdominal  than  other  operations,  especially 
when  ether  is  employed.  There  is  undoubtedly  a  hypostatic  form  of 
pneumonia  which  develops  usually  at  the  base  of  the  lungs  of  a  patient 
with  peritonitis  or  other  forms  of  sepsis.  Pleurisy  has  often  been  over- 
looked on  account  of  the  pain  having  been  ascribed  to  a  reflex  condition 
from  below. 

In  operations  upon  the  pleura,  resection  of  ribs,  etc.,  in  which  we 
already  have  extensive  infection,  or  in  paracentesis  for  abscess,  we  not 
infrequently  have  a  postoperative  extension  of  the  infection,  as  manifested 
by  acute  inflammation  of  the  lung  and  surrounding  tissues.  The  inflam- 
mation may  remain  local,  occasionally  it  extends  rapidly,  speedily  pro- 
ducing suppuration  and  ending  in  gangrene  of  a  portion  of  the  lung. 

Symptoms. — The  symptoms  of  postoperative  pneumonia  depend  upon 
the  nature  or  extent  of  the  inflammation,  whether  simple  or  septic,  and  the 
amount  of  lung  tissue  involved.   ( "International  Text  Book  of  Surgery.") 

Simple  localized  traumatic  inflammation  usually  causes  but  slight 
constitutional  disturbance,  while  the  physical  signs  will  in  most  cases 
be  obscured  by  other  conditions,  such  as  pneumothorax  and  hydrothorax. 
Spreading  septic  pneumonia,  on  the  other  hand,  is  characterized  by 
grave  constitutional  symptoms;  the  temperature  rises  to  105°  or  106°  F., 


aS  postoperative  treatment. 

the  pulse  is  rapid, — 130  to  140, — and  there  is  severe  local  pain.  The  ex- 
pectoration, which  is  at  first  bright  red,  soon  becomes  rusty  colored, 
and  there  is  marked  dyspnea.  On  examination  of  the  lungs,  the 
ordinary  signs  of  pneumonia  may  be  detected,  viz.,  dulness,  increased 
vocal  fremitus  and  vocal  resonance,  bronchial  breathing,  and  crepita- 
tion; but  not  infrequently  these  signs  are  obscured  by  the  presence  of 
fluid  in  the  pleural  cavity. 

The  prognosis,  which,  as  a  rule,  is  favorable,  will  depend  upon  the 
amount  of  lung  tissue  involved  and  on  the  presence  or  absence  of  a 
foreign  body.  Postoperative  pneumonia  shows  but  little  tendency  to 
spread,— i.  e.,  involve  the  other  lobes., — and  in  this  it  differs  essentially 
from  the  idiopathic  pneumonia. 

Treatment. — There  is  no  routine  treatment  for  postoperative  pneu- 
monia; on  the  contrary,  much  judgment  is  required  to  decide  as  to  the 
proper  management  in  every  case.  If  the  disease  is  ushered  in  suddenly 
and  the  clinical  picture  presents  evidences  of  general  acute  poisoning, 
accompanied  by  rapid  rise  of  temperature,  pain  in  the  side,  restlessness , 
and  dyspnea,  indicating  a  streptococcus  infection,  antistreptococcic 
serum  should  at  once  be  injected  subcutaneously.  When  there  is  ex- 
cessive congestion  of  the  lung  with  great  dyspnea  and  many  coarse  and 
subcrepitant  rales  over  the  lung,  relief  can  be  obtained  by  hypodermatic 
injection  of  morphin  ^  to  -|  grain  with  -^-^  grain  of  nitroglycerin; 
and,  in  addition  to  ordinary  remedies  for  the  feeble  heart,  an 
excellent  combination  is  5  grains  of  potassium  iodid,  i  minim  of 
fluid  extract  of  digitalis,  and  20  minims  of  fluid  extract  of  convallaria, 
given  every  three  hours.  Hot  saturated  solutions  of  boric  acid,  applied 
on  sterilized  absorbent  cotton  and  changed  frequently,  will  also  afford 
marked  relief.  As  a  rule,  the  patient  should  be  kept  quietly  in  bed  on  a 
fluid  diet  until  the  temperature  has  fallen  to  normal  and  the  exudate  has 
disappeared  from  the  lungs.  If  resolution  be  delayed,  or  if  broncho- 
pneumonia develop,  resort  should  be  had  to  iron,  quinin,  the  mineral 
acids,  oxygen,  cod-liver  oil,  etc.  In  elderly  people  or  old  alcoholics,  in 
whom  prostration  is  out  of  proportion  to  the  extent  of  the  lung  inflamed, 
resort  should  be  had  early  to  heart  tonics,  strychnin,  and  alcoholic 
stimulants. 

There  is  a  consensus  of  opinion  concerning  indications  for  the  treat- 
ment of  postoperative  pneumonia.  They  are:  (i)  To  relieve  the  tox- 
emia; (2)  to  prevent  failure  of  the  heart;  (3)  to  meet  complications 
as    they    arise.      To    accomplish    the   first   of   these   ends    Delancey 


POSTOPERATIVF.     COM  JM,ICATIONS.  49 

Rochester  (Builalo)  stimulates  the  skin  and  bowels  to  carry  off  the  con- 
stantly accumulating  poisons.  The  bowels  are  kept  clean  and  frequent 
liquid  stools  secured  with  daily  doses  of  ejjsom  salts,  following  calomel 
at  the  outset  of  the  disease.  Free  sweating  is  induced  by  hot  mustard 
foot-baths,  given  at  frec|uent  intervals,  the  patient  being  warmly  covered 
with  blankets.  These  baths,  in  connection  with  stimulation  to  maintain 
the  action  of  the  heart,  are  considered  the  most  important  of  the  thera- 
peutic measures.  Not  only  do  they  play  an  important  ehminative  part, 
but  by  dilating  the  capillaries  they  equalize  the  circulation  and  relieve 
the  work  of  the  heart.  To  maintain  the  work  of  the  heart  Rochester 
depends  mainly  upon  strychnin,  commenced  early  and  given  in  doses 
sufficiently  large.  Next  to  strychnin  he  places  alcohol.  In  case  there 
is  evidence  of  failure  of  the  right  heart,  he  bleeds.  Locally  he  uses 
leeches  and  cups — wet  and  dry. 

It  will  be  observed  that  the  essential  feature  of  this  treatment  is  elimi- 
native,  aimed  at  the  toxemia — the  continual  flushing  of  the  bowel  and 
the  diuresis  induced  by  the  mustard  baths.  These,  as  already  stated, 
have  a  second  and  perhaps  not  less  important  effect  in  that,  by  dilating 
the  peripheral  arterioles,  they  dissipate  the  pulmonary  stasis  which  en- 
dangers cardiac  integrity.  This  treatment,  therefore,  has  a  sound 
logical  basis.     ("Medical  Standard,"  June,  1901,) 

Postoperative  Thrombosis. — Postoperative  thrombosis  is  a  rare 
complication  most  frequently  occurring  in  anemic  subjects,  and  usuallv 
makes  its  appearance  between  the  twelfth  and  sixteenth  days  after  the 
operation.  The  clot  or  thrombus  which  forms  in  the  bloodvessels  is 
due  to  some  interruption  of  the  blood-current  at  a  definite  point.  The 
ligation  of  a  bloodvessel  close  to  the  point  of  entrance  to  the  main  trunk 
is  supposed  to  account  for  some  cases.  Thrombi  are  designated  as 
venous  or  arterial,  according  to  their  location.  The  arterial  is  far  less 
common  than  the  venous.  Septic  or  sloughing  wounds  occasionallv 
throw  off  infected  clots  which  may  be  carried  as  emboli  by  the  blood 
to  various  organs  or  parts  of  the  body.  Schenck  ("New  York  Med. 
Jour.")  found  that  out  of  a  total  of  7130  operations,  there  were  48  cases 
of  thrombosis  of  the  veins  of  the  lower  extremities.  He  concluded  that 
the  different  complications  are  therefore  more  common  after  operations 
on  the  pelvis  than  on  any  other  part  of  the  body,  due  to  pressure  upon 
or  injury  to  the  large  venous  trunk. 

Treatment. — Treatment  consists  in  absolute  rest,  and  when  an 
extremity  is  aft'ected,  wdth  moderate  elevation  of  the  hmb.  Remedies 
5 


50  POSTOPEEATIVE    TREATMENT. 

to  promote  absorption  of  the  clot  and  measures  to  prevent  detachment 
of  the  thrornbus  are  essential.  Liston's  modification  of  Mclntyre's 
splint  (Fig.  i)  is  a  suitable  apparatus  for  these  leg  cases..   Hot  applica- 


Fig.  I. — Liston's  Modification  of  McIntyre's  Splint. — (Dennis.) 

tions  of  a  saturated  solution  of  boric  acid,  alcohol,  or  Thiersch's  solu- 
tion should  be  constantly  applied  to  the  limb  and  every  effort  made  to 
promote  arterial  circulation  of  the  part.  "The  use  of  massage,  blisters, 
iodin,  and  all  counterirritants  is  contraindicated."     (Warren.) 

Morphin  or  opium  should  be  given  to  relieve  the  pain ;  nutritious  diet 
and  alcoholic  stimulants  should  be  given  when  indicated.  If  there  is 
total  occlusion  of  the  vessels  and  gangrene  occurs,  amputation  is  the 
only  remedy. 

Postoperative  Gangrene. — Postoperative  gangrene  from  femoral 
thrombosis  following  operations  upon  the  abdomen  usually  makes  its 
appearance  about  the  eighth  to  the  fifteenth  day,  as  before  alluded  to, 
but  gangrene  following  amputation  of  crushed  extremities  may  result 
from  neglecting  to  amputate  sufficiently  high  above  the  injured  part 
to  secure  good  circulation.  Plate  I  illustrates  this  condition  following 
a  Teale's  amputation  of  the  leg. 

Gangrene  Produced  by  Carbolic  Acid. — Swain  notes  that  many 
surgeons  have  discarded  the  use  of  carbolic  acid  except  for  the  immer- 
sion of  instruments  which  are  tarnished  by  solutions  of  mercury,  but 
that  it  is  not  yet  sufficiently  known  that  this  too  popular  antiseptic  is 
liable  to  cause  gangrene  when  applied  to  the  extremities  even  in  dilute 
solutions.  The  dilute  solutions  cause  no  pain,  and  are  therefore  the 
most  dangerous. 

Harrington  has  collected  a  total  of  132  cases  of  gangrene  from  dilute 


POSTOPERATIVE    COMPLICATIONS.  5 1 

solutions  of  carbolic  acid.  It  appears  from  his  observations  that  the 
damaged  condition  is  due  to  duration  of  the  application  and  to  the  thick- 
ness of  the  patient's  epidermis  more  than  to  the  strength  of  the  solution. 
Levai  is  quoted  as  saying  that  strong  solutions  are  less  dangerous  be- 
cause they  form  a  more  or  less  impervious  scab.  According  to  the  same 
observer,  the  death  of  the  part  is  due  to  a  direct  chcmic  action  on  all 
the  tissues.  Carbolic  acid  has  no  specific  quality  for  producing  gan- 
grene, for  a  hke  effect  is  produced  by  5  percent  solutions  of  hydro- 
chloric, nitric,  sulfuric,  acetic  acids,  and  by  caustic  potash  when  applied 
to  an  extremity  by  a  moistened  compress  for  about  twenty-four  hours. 
Tight  bandaging  undoubtedly  increases  the  tendency  to  this  process, 
but  experiments  have  shown  that  the  gangrene  does  not  result  primarily 
from  this  cause. 

The  TREATMENT  of  this  condition  varies  according  to  severity.  If 
it  appears  superficial,  and  the  case  is  seen  soon  after  the  removal  of  the 
carbolic  dressing,  it  would  be  beneficial  to  apply  a  dressing  saturated 
with  alcohol  or  lilne- water,  but  in  other  cases  it  soon  becomes  evident 
that  amputation  is  the  only  recourse.  The  best  prophylactic  consists 
in  the  avoidance  of  the  use  of  carbolic  acid  for  wounds,  and  it  is  the  duty 
of  physicians  to  show  by  their  example  that  the  public  should  not  make 
use  of  this  antiseptic. 

Postoperative  Cystitis. — Postoperative  cystitis  is  usually  the  result 
of  infection  following  catheterization,  hence  the  greatest  care  should 
be  exercised  in  the  sterilization  of  the  instrument  and  parts  adjacent 
to  the  external  meatus.  The  parts  should  be  well  exposed  and  cleansed 
before  the  introduction  of  a  catheter.  Despite  the  greatest  precaution, 
however,  infection  sometimes  occurs ;  hence  no  patient  should  be  cathe- 
terized  until  all  other  methods  have  been  exhausted. 

Treatment. — The  first  and  most  important  consideration  in  the 
treatment  of  cystitis  is  to  discover  the  cause  of  the  morbid  condition. 
Albuminuria  or  nephritis  the  immediate  effects  of  sulfuric  ether,  lesions 
of  the  spinal  cord,  and  constitutional  conditions  such  as  gout  and  Hthi- 
asis  must  not  be  overlooked. 

Local  treatment  of  cystitis  consists  in  the  use  of  irrigations  or  injec- 
tions with  antiseptic  solutions.  For  this  purpose  a  large  variety  of  drugs 
is  available,  including  silver  nitrate,  the  newer  silver  salts,  potassiimi 
permanganate,  boric  acid,  fluid  extract  of  hydrastis,  etc.  Irrigation  by 
means  of  a  double  catheter  should  be  employed  and  repeated  two  or  three 
times  a  day.     One  of  the  best  means  of  flushing  the  bladder  and  dimin- 


52  POSTOPERATIVE    TREATMENT. 

ishing  the  irritating  effect  of  the  urine  is  to  let  the  patient  drink  abundantly 
of  pure  hot  water.  If  mineral  waters  are  preferred,  they  should  not  be 
carbonated,  as  this  sometimes  acts  as  an  irritant.  Internally,  the  bal- 
sams, such  as  copaiba,  cubebs,  and  sandal- wood,  are  much  less  frequently 
prescribed  than  formerly,  and  this  applies  as  well  to  such  remedies  as 
buchu,  triticum  repens,  corn-silk,  uva  ursi,  etc.  At  the  present  time 
urotropin  enjoys  the  greatest  popularity,  its  action  depending  upon  the 
liberation  of  formaldehyd  in  the  urine,  which  is  thereby  prevented  from 
undergoing  decomposition,  while  the  pathogenic  organisms  are  either 
destroyed  or  inhibited  in  their  growth.  The  value  of  urotropin  has 
been  fully  established  by  numerous  observations,  but  more  recently 
attention  has  been  called  to  the  fact  that  in  some  cases  its  use  is  not  devoid 
of  injurious  consequences;  thus,  it  may  give  rise  to  gastric  disturbances, 
diarrhea,  hematuria,  and  strangury.  These  by-effects  may  be  obviated 
by  giving  the  drug  well  diluted,  and  by  reducing  the  dose  in  cases  in 
which  the  urine  is  very  acid,  or  by  giving  it  in  alternate  doses  with  a 
saturated  solution  of  sodium  phosphate.  Urotropin  sometimes  fails 
to  act  in  cases  of  ammoniacal  fermentation,  in  which  case  the  urine 
should  be  rendered  slightly  acid  or  the  bladder  irrigated  frequently, 
and  kept  as  nearly  empty  as  is  possible. 

For  the  treatment  of  more  severe  cases  of  cystitis  the  reader  is  re- 
ferred to  articles  upon  this  subject  as  discussed  in  text-books. 

Postoperative  Neurasthenia. — Postoperative  neurasthenia  is  be- 
coming quite  common,  and  is  certainly  the  most  annoying  and  intract- 
able of  all  postoperative  neuropsychoses.  It  is  now  an  established  fact 
that  the  injury  and  shock  of  surgical  operations  may  be  followed  by 
symptoms  of  well-recognized  neuroses  or  pyschoses,  or  the  symptoms 
of  one  or  more  of  these  disorders  may  be  blended  in  the  same 
case.  Many  of  these  are  mixtures  of  hysteria  and  neurasthenia; 
others  may  be  shown  to  depend  upon  the  structural  changes  in  the 
central  nervous  system  of  which  the  clinical  manifestations  are  associ- 
ated with  symptoms  of  hysteria  and  neurasthenia.  In  postopera- 
tive neurasthenia  the  mental  state  is  subject  to  wide  variations.  The 
disorders  assume  the  type  of  hj^ochondriasis  less  frequently  than  melan- 
cholia or  dementia. 

Hysteria  or  neurasthenia  following  surgical  operations  is  not  always 
of  the  pure  type  seen  when  the  affection  develops  in  men  or  women  from 
nontraumatic  causes,  and  whether  it  is  due  to  the  trauma,  directly  attrib- 
utable to  the  operation,  the  result  of  fright,  or,  lastly,  the  effects  of  the 


POSTOPERATIVE     COMPLICATIONS.  53 

anesthetic  used,  has  as  yet  to  be  determined.  By  far  the  larger  number 
of  cases  of  postoperative  hysteria  or  neurasthenia  may  be  explained  on 
the  assumption  that  the  symptoms  are  those  of  hysteria  or  neurasthenia, 
functional  disorders  of  which  the  pathology  is  unknown,  the  symptoms, 
as  a  rule,  differing  in  no  essentials  from  those  of  organic  nervous  disease. 
When  the  factors  are  active  in  the  production  of  postoperative  neuras- 
thenic symptoms,  an  important  place  is  occupied  by  previous  disposition, 
either  hereditary  or  acquired  through  excesses.  In  hysteria  and  neuras- 
thenia originating  from  causes  other  than  trauma  it  often  may  be  dis- 
covered that  previous  to  the  appearance  of  symptoms  the  resisting  powers 
of  the  nervous  system  had  become  enfeebled  through  various  causes. 
Unfortunately,  however,  postoperative  neurasthenia  frequently  appears 
in  persons  previously  healthy  and  active,  and  it  is  often  impossiVjle  to 
discover  any  predisposition  thereto.  The  influence  of  "suggestion" 
by  sympathizing  friends  is  frequently  an  important  factor  in  the  causa- 
tion of  both  postoperative  neurasthenia  and  hysteria.  In  many  cases 
it  seems  as  though  these  disorders  or  their  appearance  are  in  a  great 
degree  due  to  the  fact  that  the  sufferers  have  been  told  by  sympathizing 
friends  of  the  terrible  ordeal  through  which  they  have  passed.  Examples 
of  the  bad  effect  of  such  statements  are  numerous.  The  following  is 
a  typical  case  of  this  character: 

Mrs.  A.  B.,  aged  thirty-four,  a  very  stout  and  apparently  rugged  woman 
of  German  descent,  was  the  wife  of  a  well-to-do  farmer,  but  had  always  been 
accustomed  to  doing  heavy  indoor  and  outdoor  work ;  had  borne  no  children. 
During  the  summer  of  1900  she  complained  of  occasional  abdominal  pains 
and  menstruation  became  somewhat  profuse.  Upon  examination  later  it 
was  discovered  that  she  was  afflicted  with  a  fibroma  of  the  uterus.  In  Alarch, 
1 90 1,  myomectomy  was  performed.  The  recovery  from  the  operation  was 
rapid  and  no  ill  results  were  apparent.  A  few  months  after  the  operation 
there  supervened  a  condition  of  extreme  nervousness,  irritability,  sleepless- 
ness, and  despondency.  She  finally  settled  upon  the  conviction  that  the 
operation  had  not  been  performed  in  a  skilful  manner.  Her  physical  con- 
dition was  perfect,  menstruation  normal  and  regular,  appetite  ver\^  good, 
bowels  regular,  pulse-rate  and  temperature  normal,  and  no  evidence  of 
organic  disease.  The  skin  over  the  whole  body  was  h}-persensitive.  The 
patient  finally  became  bedfast.  So  persistent  was  she  that  something  was 
wrong  within  the  abdominal  cavity  that  an  exploratory  laparotomy  was  per- 
formed with  the  hope  of  at  least  eft'ecting  a  mental  cure.  This  operation 
was  performed  in  June,  1901.     Nothing  whatever  abnormal  Avas  discovered, 


54  POSTOPERATIVE    TREATMENT. 

no  adhesions  were  found,  patient  recovered  from  the  operation  and  returned  to 
her  home  greatly  improved,  and  was  able  to  do  her  own  housework.  Later,  how- 
ever, she  gradually  passed  into  her  former  condition.  In  August,  1902,  about 
fourteen  months  after  the  last  operation,  she  was  bedfast.  An  examination 
failed  to  find  any  evidence  of  organic  or  nerve  injury,  there  was  no  contraction 
of  visual  field,  no  paralysis,  no  disturbance  of  the  functions  of  the  bowels, 
bladder,  or  ovaries.  The  patient  was  depressed,  tremulous,  and  anxious, 
skin  was  hypersensitive,  pressure  over  the  vertebras  caused  expressions  of 
pain.  She  complained  of  gaseous  distention  after  eating,  and  persisted  in 
her  refusal  to  sit  up  or  walk.     Evidently  a  confirmed  neurasthenic. 

Neurasthenia  arises,  according  to  some  authors,  from  a  general  defect 
in  the  nutrition  and  action  of  the  nervous  system,  or  the  result  of  re- 
flex irritation  or  degenerative  changes  in  the  nerves.  It  may  follow 
surgical  shock  or  exhaustion  of  the  nervous  system.  In  my  experience 
the  severity,  character,  or  extent  of  the  operation  has  no  special  deter- 
mining influence.  Functional  neuroses  often  follow  minor  surgical 
traumatisms. 

Symptoms. — The  general  characteristics  of  neurasthenia  are  so 
familiar  as  not  to  require  repetition  here.  Patients  complain  of  exhaus- 
tion, mental  irritability,  loss  of  memory,  disturbed  sleep,  headache, 
palpitation  of  the  heart,  dyspeptic  trouble,  foul  breath,  constipation, 
nausea,  etc.  (Thorburn.)  All  symptoms  tend  toward  chronicity;  many 
are  sensitive  or  emotional  and  subject  to  migratory  or  neuralgic  pains 
in  the  abdomen,  limbs,  or  head.  There  is  very  frequently  no  impair- 
ment of  general  nutrition.  The  absence  of  organic  lesions  or  disease,  and 
of  distinct  symptoms  denoting  the  existence  of  pathologic  changes,  sim- 
plifies the  diagnosis.  While  it  is  true  that  many  of  these  cases  are 
complicated  by  the  hope  of  legal  redress,  yet  they  frequently  occur  in- 
dependent of  "suggestion"  or  the  counsel  of  friends  or  lawyers.  The 
symptoms  are  often  complicated  by  exaggerated  or  purely  imaginary 
troubles ;  and  the  reflexes  are  usually  abnormal. 

Nature,  Duration,  and  Severity  of  Case. — No  very  important 
conclusions  can  be  drawn  from  the  nature  of  the  case — that  is,  whether 
it  is  of  a  hysteric  or  neurasthenic  character — as  regards  the  prognosis. 
(Warren.)  The  duration  of  symptoms  is  indefinite,  owing  to  the 
tendency  to  the  formation  of  "associated"  neuroses.  Many  of  these 
patients  become  chronic  hypochondriacs,  yet  because  of  the  fact  that  the 
symptoms  as  a  whole  are  often  the  result  of  delusion,  efforts  should  be 
made  to  relieve  their  pitiable  condition,  and  the  patient  should  have 


POSTOPERATIVE    COMPLICATIONS.  55 

the  benefit  of  thorough  expert  treatment.  The  features  that  make  the 
prospect  of  recovery  unfavorable  are  neurotic  temperament,  lack  of 
firmness  or  a  natural  tendency  to  nervous  depression,  and  loss  of 
will-power,  energy,  or  desire  for  recovery.  Many  assume  a  form  of 
lethargy  or  morbid  inaction,  from  which  nothing  arouses  them,  and  they 
remain  thus  for  years.  True  neurasthenia  is  an  obstinate  and  tedious 
affection;  the  hysteric  form  is  less  serious. 

Diagnosis. — "The  physician,  in  approaching  a  case  assumed  to  be 
one  of  the  posttraumatic  neuroses,  is  obliged  to  consider,  first,  whether 
the  patient  is  simulating  or  is  really  ill;  next,  the  type  of  the  illness,  if  it 
exists;  and,  further,  to  what  extent  it  may  be  considered  as  superficial 
and  under  the  domination  of  excitement  and  the  events  of  the  operation 
or,  on  the  other  hand,  due  wholly  or  in  part  to  actual  lesions  of  the  ner- 
vous system  or  to  profound  disorders  of  circulation  and  nutrition.  It  is 
his  duty  to  determine  how  far  it  may  be  attributed  to  the  action  of 
previously  existing  neuropathic  tendencies,  or  contributive  degeneracies 
of  other  origin,  or  to  other  causes  not  connected  with  the  operation." 
(Warren  and  Gould,  "International  System  of  Surgery.")  As  regards 
the  commoner  types  of  disease  (hysteria,  neurasthenia,  the  psychoses, 
the  spinal  scleroses,  the  cerebral  and  spinal  degenerations  of  vascular 
origin,  strain  of  the  lumbar  muscles,  spondylitis  secondary  to  injury 
of  the  vertebras,  etc.),  while  the  diagnosis  in  well-marked  cases  is  easy, 
there  are  certain  essential  considerations  to  be  borne  in  mind.  The 
chief  of  these,  according  to  Bailey,  are  the  following:  It  is  important 
to  distinguish  between  true  neurasthenia  and  hysteric  neurasthenia,  the 
former  being  a  more  severe  affection  than  the  latter.  The  psychoses 
may,  on  the  same  principle,  have  a  hysteroid  element  in  them,  the  spinal 
scleroses  and  subacute  myelitis  may  be  simulated  by  hysteria  or  hysteroid 
affection,  though  a  judicial  consideration  of  the  whole  case  wiU  generally 
make  the  diagnosis  possible.  Finally,  it  is  important  to  note  that 
hysteria  may  coexist  with  organic  affections,  so  that  the  physician  must 
be  prepared  to  diagnose  both  conditions  separately. 

Treatment. — Enforced  rest,  as  suggested  by  S.  Weir  Mitchell,  abso- 
lute isolation  from  friends  and  relatives,  cauterization  of  the  back  of  the 
neck,  as  recommended  by  Shoemaker,  correction  of  the  digestive  func- 
■  tions,  chalybeates  and  tonics  as  required,  and,  lastly,  static  electricity,  com- 
plete the  list  of  methods  of  treatment  suggested  by  the  best  authorities 
for  the  relief  of  this  condition. 


56  POSTOPERATIVE    TREATMENT. 

Postoperative  Insanity. — Postoperative  insanity,  like  other  post- 
operative neuroses,  bears  no  definite  relation  to  the  character  or  extent 
of  the  operation  performed,  and  is  of  itself  a  comparatively  rare  oc- 
currence. The  majority  of  the  cases  reported  can  be  attributed  to  the 
effects  of  the  anesthetic  and  most  frequently  occur  among  patients 
predisposed  to  attacks  of  insanity ;  or  they  may  be  due  to  acute  sepsis  or 
metastatic  cerebral  abscess  resulting  from  operation,  in  which  case  we 
have  a  rise  of  temperature  and  other  acute  symptoms  denoting  infection. 
These  cases,  although  presenting  symptoms  of  acute  mania,  should  not 
be  classed  as  postoperative  insanity.  The  true  type  of  postoperative 
insanity  may  be  justly  attributed  to  morbid  brooding,  fright,  or  mental 
anxiety  over  the  operation,  or  from  the  previously  diseased  condition 
calling  for  operative  interference,  and  not  to  the  operation  per  se.  Oper- 
ations upon  neurotic  individuals  or  persons  of  high-strung  nervous  tem- 
perament are  frequently  followed  by  hysteria  or  neurasthenia,  as  here- 
tofore described.  Picque  and  Brand  ("Med.  Bulletin")  have  published 
an  important  paper  upon  mental  disturbances  or  psychoses  following 
surgical  operations.  Under  the  term  "postoperative  psychoses"  they 
include  only  delusions  with  or  without  mental  confusion,  and  affecting 
the  intellectual  functions  only.  Neurasthenia,  hysteria,  or  hypochon- 
driac characters  or  other  neuroses  are  not  included  in  the  category 
of  postoperative  psychoses.  All  forms  of  cerebral  excitement  or  de- 
lirium which  persist  after  the  operation,  and  which  may  be  attributed  to 
an  undue  sensitiveness  of  the  patient  to  the  anesthetic,  are  stigmatized 
as  "toxic  pseudodelirium,"  which  is  of  transient  character,  lasting,  as  a 
rule,  but  a  few  days.  True  postoperative  psychoses  are  serious  forms 
of  mental  disturbance  which  require  care  and  treatment  in  an  institu- 
tion. 

Symptoms. — The  symptoms  of  postoperative  insanity  are  variable. 
They  comprise  maniacal  excitement,  delusions  of  persecution,  and 
melancholic  depression,  accompanied  frequently  with  suicidal  tend- 
encies. 

Treatment. — When  there  is  the  slightest  indication  of  insanity, 
the  patient  should  always  be  under  the  charge  of  a  constant  attendant. 
Rest,  careful  attention  to  general  nutrition  and  hygiene,  isolation 
from  friends,  with  judicious  employment  of  nerve  tonics,  valerian,  and 
hyoscyamus,  with  hypnotics  and  general  tonics  as  indicated. 

Postoperative  delirium  frequently  results  from  prolonged  fasting 
and  exhaustion  of  the  nerve-centers  incident  thereto.     This  is  often 


POSTOPERATIVE     COMPLICATIONS.  57 

noticeable  after  operations  upon  the  stomach  and  intestinal  tract, 
in  which,  from  long-continued  suffering  and  fluid  diet,  the  patient  finally 
loses  his  mental  equipoise,  and  symptoms  of  mania  or  melancholia 
agitans  supervene  with  little  or  no  warning. 

The  personal  experience  of  the  author  warrants  him  in  emphasiz- 
ing the  statement  that  it  not  infrequently  happens  in  these  enfeebled 
patients  that  the  long-continued  use  of  iodoform,  powder  or  gauze 
drainage,  increases  the  tendency  to  delirium,  or  may  possibly  be  the 
exciting  cause  thereof.  An  examination  of  the  urine  should  therefore 
be  made,  and  if  iodin  is  found,  other  forms  of  antiseptic  or  aseptic 
dressings  should  be  substituted. 

The  prognosis  in  this  form  of  delirium  is  usually  favorable,  but  the 
period  of  convalescence  may  be  greatly  protracted. 

Postoperative  Jaundice. — R.  DeBovis  reports  two  cases  of  jaundice 
following  surgical  and  obstetric  operations.  The  first  was  in  a  young 
man  upon  whom  he  operated  for  a  small  inguinal  hernia.  Chloroform 
was  used  as  an  anesthetic  and  the  operation  lasted  about  half  an  hour. 
Healing  occurred  by  first  intention.  On  the  second  day  jaundice  ap- 
peared, which  by  the  third  day  had  increased  in  intensity.  The  urine 
was  characteristic  of  this  condition.  The  temperature  and  pulse  were 
normal.  Toward  the  sixth  day  the  jaundice  began  to  disappear  rapidly. 
The  second  case  was  that  of  a  woman  in  whom  there  was  rigidity  of  the 
OS  uteri  during  labor,  due  to  thickening  and  cicatrization  from  previous 
labors.  In  order  to  facilitate  dehvery,  the  tissues  were  incised  under 
anesthesia.  Three  days  later  jaundice  appeared,  and  was  accom- 
panied by  a  slight  elevation  of  temperature.  It  diminished  gradually, 
and  when  she  was  discharged,  twelve  days  later,  it  had  entirely  dis- 
appeared. Similar  cases  have  been  reported  by  various  writers.  De 
Bovis  believes  that,  aside  from  jaundice  due  to  operations  upon  the  gall- 
ducts,  which  is  of  grave  prognosis,  there  is  a  form  of  jaundice  following 
operations  which  is  benign  in  character  and  of  short  duration,  due 
to  simple  biliary  retention  by  reflex  action.  The  author  has  seen 
several  cases  of  postoperative  jaundice  occurring  from  the  third  to  the 
sixth  day.  The  attacks  are  usually  of  a  mild  type  and  subside  without 
special  medical  treatment  in  from  eight  to  ten  days. 

Mayo  Robson  has  recently  drawn  attention  to  the  value  of  cal- 
cium chlorid  in  the  treatment  of  patients  suffering  from  jaundice  at 
the  time  of  operation.  He  administers  the  drug  by  the  rectum  in 
doses  of    60  grains,  thrice  daily,  until    all   signs    of  oozing  from  the 


58  POSTOPERATIVE    TREATMENT. 

wound  have  ceased.  It  is  better,  however,  to  use  this  drug  as  a  prophy- 
lactic agent,  beginning  administration  two  or  three  days  prior  to  opera- 
tion. It  is  claimed  that  if  administered  for  longer  than  three  or  four 
days,  in  large  doses,  it  actually  diminishes  the  coagulability  of  the 
blood.  Ruspini's  styptic  (Liquor  ferri  perchloridi  with  an  equal  part  of 
tincture  of  matico)  is  recommended  by  English  writers,  and  is  best  applied 
by  soaking  narrow  pieces  of  lint  and  then  carefully  packing  the  wound 
and  applying  pressure  over  it. 

Postoperative  Erysipelas. — This  is  a  form  of  infection  characterized 
by  an  acute  inflammation  of  the  skin  and  deeper  structures,  accompanied 
with  fever  and  general  constitutional  disturbance.  The  affected  area  is 
usually  well  defined,  the  skin  assuming  a  red  or  crimson  color,  or  may 
appear  of  a  slightly  purple  color  and  shine  or  glisten  from  edema  of  the 
parts.  The  skin  becomes  hot  and  tender  to  the  touch  and  blebs  or 
vesicles  later  make  their  appearance.  The  affection  is  due  to  the  in- 
troduction of  Streptococcus  erysipelatis.  The  cocci  may  enter  directly 
through  the  wound  and  from  this  point  spread  rapidly  through  the 
lymphatics  or  capillaries  to  the  surrounding  tissues,  or  if  the  patient 
happens  to  be  afflicted  with  a  local  form  of  erysipelas  at  the  time  of  the 
operation,  the  operative  wound,  though  at  a  distance,  may  later  become 
infected  by  the  cocci  being  carried  through  the  circulatory  system. 

The  following  case  seems  to  warrant  the  belief  that  the  virus  may  be 
transmitted  through  the  circulation : 

G.  S.,  aged  thirty-one,  farm-hand,  was  suffering  from  an  acute  attack  of 
facial  erysipelas  to  which  he  was  frequently  subject.  In  going  to  his  home 
in  an  adjacent  county  he  unfortunately  had  his  right  foot  crushed  in  at- 
tempting to  board  a  moving  freight  train,  necessitating  the  amputation  of 
the  toes  and  a  part  of  the  foot.  Every  precaution  possible  was  taken  at 
the  time  of  the  operation  to  prevent  infection  of  the  operative  wound,  but 
on  the  fifth  day  erysipelas  of  a  phlegmonous  character  developed  in  the 
wound,  requiring  numerous  incisions  and  constant  irrigation.  The  patient 
was  confined  to  his  bed  several  weeks,  but  ultimately  made  a  good  recovery. 

As  to  whether  or  not  erysipelas  is  communicable  or  contagious 
is  still  a  much  argued  question ;  the  majority  of  surgeons  favor  the  idea, 
and  the  abundance  of  clinical  proof  offered  appears  to  warrant  the  belief 
that  the  disease  is,  at  least  in  some  of  its  forms,  communicable.  In  these 
days  of  aseptic  surgery  it  may  be  possible  for  a  patient  with  erysipelas 
to  remain  in  a  surgical  ward  without  contaminating  others,  but  there  are 


POSTOPERATIVE   COMPLICATIONS.  59 

cases  of  such  virulence,  especially  of  the  phlegmonous  type,  which 
should,  in  my  opinion,  be  promptly  isolated  and  the  strictest  measures 
taken  to  prevent  possible  contagion.  I  believe  isolation  to  be  the  safest 
and  most  rational  course  to  pursue,  even  in  the  mildest  of  cases,  and 
I  would  be  unwilling  to  permit  a  patient  afflicted  with  any  form  of 
erysipelas  to  enter  my  surgical  ward. 

Symptoms. — The  disease  may  appear  any  time  during  the  heahng 
of  the  wound,  but  usually  commences  from  four  to  seven  days  following 
the  operation.  There  are,  as  a  rule,  certain  premonitory  symptoms 
preceding  the  actual  attack,  such  as  malaise,  headache,  loss  of  appetite, 
and  a  feeling  of  tension  and  pain  about  the  wound.  In  other  cases  the 
disease  may  begin  suddenly  with  a  severe  rigor,  without  any  premonitory 
symptoms.  However  the  attack  may  be  ushered  in,  it  is  followed  by  a 
rapid  rise  in  temperature  to  about  104°  F.  Along  with  the  rise  in  tem- 
perature there  is  headache,  probably  nausea  and  vomiting,  a  rapid,  soft 
pulse,  foul  tongue,  great  thirst,  scanty  urine,  diminution  of  the  discharge 
from  the  wound,  and  swelling  of  the  neighboring  lymphatic  glands,  to 
which  latter  there  may  be  red  Hnes  running  from  the  wound.  Oc- 
casionally there  is  acute  delirium.  In  from  ten  to  twenty-four  hours 
after  the  rigor  a  red  or  crimson  blush,  sharply  marked  off  from  the 
surrounding  parts,  appears  around  the  wound,  and  the  reddened  portion 
is  somewhat  swollen.  The  redness  increases  and  usually  spreads  along 
the  course  of  the  lymphatic  vessels,  that  is  to  say,  toward  the  trunk.  The 
margin  of  the  inflammation  can  be  felt  as  a  distinctly  elevated  ridge. 
Where  the  tissues  are  lax,  as  in  the  eyelids  or  the  scrotum,  the  swelhng 
may  be  very  great,  and  bullas  may  form  upon  the  surface.  BuUas  may 
also  appear,  although  not  so  frequently,  when  the  trunk  or  limbs  are 
affected.  During  the  course  of  the  disease  there  is  often  albuminuria. 
After  six  or  eight  days  there  is  generally  a  rapid  fall  of  the  temperature, 
which  has  remained  high  during  the  acute  period.  The  constitutional 
symptoms  disappear,  the  appetite  improves,  the  redness  gradually 
fades  and  usually  disappears  by  the  middle  of  the  second  week ;  finally, 
desquamation  occurs.  This  desquamation  is  of  great  importance 
because  it  is  in  the  scales  of  epidermis  that  the  chief  source  of  the  ery- 
sipelas infection  is  to  be  found.  In  severe  cases  the  disease  may  end 
fatally,  during  the  second  week,  from  pyrexia  and  general  exhaustion. 
The  most  serious  form  of  erysipelas  is  described  as  phlegmonous  or 
gangrenous.  In  such  cases,  along  with  the  symptoms  already  described, 
there  is  suppuration  into  the  subcutaneous  tissues,  which  sometimes  takes 


6o  POSTOPERATIVE    TREATMENT. 

the  form  of  an  abscess,  but  more  commonly  manifests  itself  by  a  diffuse 
cellulitis;  occasionally  the  skin  sloughs  together  with  the  deeper  tissues. 
In  these  cases  the  patient  usually  soon  passes  into  a  typhoid  state  and 
death  frequently  occurs. ' 

Treatment. — The  treatment  of  erysipelas  is  both  constitutional 
and  local.  The  internal  treatment  should  be  supportive;  antipyretics 
and  purgatives  and  other  depleting  remedies  should  be  avoided,  since 
the  system  requires  strength  to  combat  the  sepsis.  Mild  and  agreeable 
tonics  v^ith  proper  nourishment  are  usually  all  that  is  necessary.  The 
much  extolled  remedy,  tincture  of  the  chlorid  of  iron,  as  recommended  by 
Hamilton  Bell  and  other  English  writers,  has  proved  of  very  little  value 
except  in  chronic  cases,  and  has  now  been  abandoned  by  many  surgeons. 
In  case  the  infection  is  pronounced  and  the  temperature  rises  to  103°, 
104°,  or  105°  F.,  antistreptococcic  serum  frequently  proves  of  marked 
benefit,  and  should  always  be  used  in  severe  cases.  In  the  aged  and 
feeble  or  in  those  broken  down  by  wasting  diseases  alcoholic  stimulants 
are  of  value  if  used  judiciously.  To  control  delirium  the  bromids,  chlo- 
ral, or  hyoscin  may  be  employed  with  safety,  and,  lastly,  a  mild  aperient, 
such  as  effervescent  sodium  sulfate  in  dram  doses,  should  be  given  as 
required. 

Local  Treatment. — Lotions  and  ointments  innumerable  have  been 
recommended.  In  the  rapidly  spreading  forms  of  erysipelas  strenuous 
efforts  should  be  made  to  check  the  progress  of  the  disease.  The  old 
method  of  drawing  a  line  on  the  skin  around  and  above  the  area  of  red- 
ness, with  silver  nitrate,  or  painting  the  skin  in  a  similar  manner  with 
iodin  or  creasote,  may  still  be  used  with  good  results  if  employed  early. 

Kraske's  method  of  making  numerous  small  scarifications  in  the 
skin  around  and  above  the  seat  of  infection  acts  on  the  same  principle, 
but  likewise  must  be  employed  early  if  benefit  is  to  be  expected.  Later, 
injections  of  a  2  percent  solution  of  carbolic  acid,  as  recommended 
by  F.  P.  Henry,  although  at  times  painful,  often  yield  excellent  results. 
The  injections  should  not  be  made  into,  but  a  little  beyond,  the  border 
of  the  inflamed  parts.  The  needle  of  the  syringe  should  be  pushed  in 
various  directions  under  the  epidermis  in  order  to  disseminate  the  fluid 
as  extensively  as  possible.  Injections  may  be  repeated  once  daily  and 
gradually  increased  to  twice  or  three  times  a  day,  using  about  one  flui- 
dram  of  the  solution  at  each  insertion.  Solutions  of  salicylic  acid,  5 
to  10  percent,  and  sodium  sulfocarbolate,  20  percent,  have  also  been 
used  subcutaneously  with  advantage. 


POSTOPERATIVE    COMPLICATIONS.  6 1 

Topical  Applications. — Of  the  numerous  topical  applications 
recommended,  a  solution  of  creolin,  one-half  to  one  dram  in  a  jjint  of 
sterile  water,  appears  to  have  proved  the  most  beneficial.  It  is  nontoxic 
and  may  be  applied  over  large  surfaces.  Lint  kept  constantly  moist  with 
the  old-fashioned  lead  and  opium  wash  is  frequently  very  soothing  anrl 
tends  to  allay  the  itching  and  burning  of  the  inflamed  wound  or  skin. 
Later,  when  desquamation  is  noticed,  ointments  or  oleates  act  better. 
Ichthyol  ointment,  lo  percent,  eucalyptol  ointment,  zinc  oxid  ointment, 
castor  oil,  or  plain  cosmolin  will  not  only  tend  to  allay  irritation,  but 
lessen  the  chance  of  dissemination  of  the  infective  desquamating  epi- 
thelium. 

Treatment  of  the  Phlegmonous  Types. — The  graver  forms  of 
phlegmonous  or  gangrenous  erysipelas,  or  malignant  edema,  must  be 
dealt  with  promptly  and  heroically  by  long  and  deep  incisions.  Many 
lives  have  been  saved  by  the  prompt  interference  of  the  surgeon.  Warren 
states  that  free  incisions  allow  the  escape  of  the  pent-up  discharges,  and 
free  drainage  prevents  the  invasion  of  bacteria  and  their  products  into 
the  lymphatic  system,  hence  free  drainage  is  the  prime  factor  in  the 
successful  treatment  of  these  cases,  after  which  constant  irrigation  should 
be  carried  out  in  the  manner  described  under  the  treatment  of  septic 
wounds. 

Postoperative  Peritonitis. — The  treatment  of  postoperative  peri- 
tonitis varies  greatly;  the  cause  of  this  variance  being  possibly  the 
vast  difference  in  the  type  and  severity  of  the  infection.  A  small 
localized  collection  of  pus  in  the  abdominal  cavity  often  becomes  safely 
walled  off  in  a  few  hours,  while,  on  the  other  hand,  the  infection  of 
the  central  portion  of  the  abdominal  cavity  is  inevitably  fatal  unless 
prompt  surgical  interference  is  adopted. 

Before  entering  upon  the  subject  of  operative  treatment,  which  is 
called  for  in  a  large  majority  of  the  cases,  it  may  be  well  to  indicate  the 
scope  and  limits  of  purely  medical  means.  If  the  diagnosis  has  been 
made  early  and  the  condition  is  mild  or  localized,  divided  doses  of  calo- 
mel, followed  by  a  brisk  saline  purge,  may  serve  to  remove  some  of  the 
fermenting  contents  of  the  bowels  and  assist  in  the  removal  of  the  toxins 
from  the  peritoneal  cavity.  But  it  must  always  be  borne  in  mind  that 
the  formation  of  adhesions  or  the  possibility  of  perforations  is  an  absolute 
contraindication  to  the  use  of  any  laxative,  so  that  the  use  of  such  treat- 
ment has  come  to  be  limited  to  postoperative  cases.  Local  measures — 
application  of  cloths  saturated  with  alcohol,  applied  as  hot  as  possible 


62  POSTOPERATIVE    TREATMENT. 

poultices,  Stupes,  ice-coils,  and  the  like — serve  chiefly  to  make  the  pa- 
tient more  comfortable,  and  probably  influence  very  little  the  actual 
course  of  the  disease.     ("  Text-book  of  International  Surgery.") 

Believing  that  the  presence  of  fluid  in  the  peritoneal  cavity  favors 
extension  of  the  disease,  and  that  the  pelvic  peritoneum,  from  its  lessened 
capacity  for  absorption,  is  better  able  to  combat  infection,  Fowler 
(Brooklyn)  ("New  York  Medical  Record")  has  treated  patients  by 
elevating  the  head  of  the  bed  in  order  to  facilitate  the  passage  of  septic 
fluids  from  the  general  peritoneal  cavity  to  that  of  the  pelvis,  where  they 
would  do  less  harm  and  be  more  readily  removed  by  drainage  methods. 
He  insists  that  the  elevation  of  the  head  of  the  bed  shall  exceed  the  foot 
by  at  least  12  to  15  inches.  A  large  pillow  is  placed  beneath  the  knees 
and  the  buttocks  are  allowed  to  rest  against  this  to  prevent  the  body 
sliding  down.  The  pillow  is  made  fast  by  a  bandage  to  the  sides  of  the 
bed.  A  number  of  patients  were  treated'  by  this  method  with  satis- 
factory results. 

Should  operative  measures  be  decided  upon,  shock  is  to  be  avoided 
by  the  use  of  an  anesthetic,  and  ether  is  perhaps  the  best  for  its  stimu- 
lant effect  upon  cardiac  muscle  already  weakened  by  the  action  of  the 
absorbed  toxins.  To  aid  the  general  anesthesia  and  to  diminish  the 
amount  of  ether  necessary  to  prevent  any  movement  on  the  part  of  the 
patient, — for  that  is  all  that  is  required, — a  moderate  preliminary  dose 
of  morphin  hypodermatically  is  valuable.  Its  effects  are  also  desirable 
after  the  operation  in  quieting  the  patient  and  diminishing  peristalsis, 
and  it  in  no  way  interferes  with  subsequent  treatment  by  means  of  laxa- 
tives. In  extreme  cases  it  is  best  to  employ  cocain,  or  cocain  combined 
with  morphin,  for  purposes  of  anesthesia,  because  any  general  anesthetic 
would  inevitably  be  fatal.  A  very  thorough  cleansing  operation  is 
almost  impossible  under  cocain,  yet  enough  can  be  done  by  abundant 
irrigation  and  subsequent  drainage  to  give  the  patient  his  best  chance 
for  life. 

One  procedure  which  should  never  be  omitted  previous  to  operation 
upon  patients  in  whom  there  has  been  fecal  vomiting,  or  even  a  tendency 
to  intestinal  paresis  and  gaseous  distention,  is  a  thorough  lavage  of 
the  stomach.  This  simple  procedure  obviates  many  of  the  dangers  of 
a  general  anesthetic.  There  can  be  no  infection  of  the  air-passages, 
with  subsequent  septic  pneumonia,  because  the  patient  does  not  re- 
gurgitate the  foul  contents  of  his  stomach  and  upper  bowel.  There 
is  less  likelihood,  also,  of  persistent  vomiting  after  the  operation,  and 
the  patient  gains  a  period  of  relief  and  quiet. 


POSTOPERATIVE    COMPLICATIONS.  63 

The  choice  of  an  incision  depends  largely  upon  the  condition  one 
expects  to  find.  If  the  infection  follows  an  appendicectomy  or  the  break- 
ing of  an  abscess  into  the  peritoneal  cavity,  and  if  the  symptoms  do  not 
point  to  a  general  invasion  of  the  whole  peritoneum,  the  opening  should 
be  made  with  a  view  to  giving  the  best  possible  exposure  of  the  field  to 
which  the  trouble  may  be  confined.  On  the  other  hand,  if  the  patient's 
condition  shows  that  the  infection  has  become  a  generalized  one,  the 
incision  should  be  made  in  the  median  line,  and  long  enough  to  give 
free  access  to  all  parts  of  the  abdominal  cavity.  There  are  then  two 
methods  of  procedure:  (i)  Careful  mopping  up  of  all  exudate  from 
the  cavity  and  the  loops  of  the  gut,  and  (2)  free  irrigation  with  hot  nor- 
mal salt  solution.  The  choice  depends  on  the  condition  found.  If 
the  process  is  spreading,  but  does  not  as  yet  involve  the  whole  of  the 
peritoneum,  it  is  improper  to  irrigate  and  thus  spread  the  infection  to 
tissues  still  intact.  The  rarity  of  a  universal  peritonitis  is  seldom  appre- 
ciated. What  usually  passes  for  this  condition  is  a  fairly  well  localized 
inflammation  without  any  limiting  adhesions.  In  such  conditions  it 
is  wiser  carefully  to  sponge  out  all  the  visible  exudate  with  pads  of  sterile 
gauze  which  have  been  wrung  out  of  hot  normal  salt  solution.  A  cer- 
tain amount  of  traumatic  injury  is  necessarily  inflicted,  but  this  is  far 
more  easily  cared  for  by  nature  than  the  additional  toxemia  which  would 
inevitably  follow  irrigation.  This  cleansing  process  should  never  extend 
beyond  the  visible  Hmits  of  the  disease;  the  remainder  of  the  abdominal 
cavity  is  to  be  protected  carefully  by  large,  dry,  steriHzed  gauze  pads 
passed  between  the  intestines  and  the  abdominal  wall,  to  be  left  until 
all  the  cleansing  process  is  over.  The  removal  of  these  pads  from  the 
abdomen  is  much  facihtated  by  having  a  long  tape  firmly  stitched  to 
one  corner;  this  also  relieves  the  operator  from  the  embarrassment  and 
doubt  of  having  left  a  pad  in  the  abdomen.  When  the  infection  is  un- 
doubtedly general,  the  patient's  Hfe  should  not  be  risked  by  any  pro- 
longed search  for  the  site  of  the  perforation,  but  an  ample  median  in- 
cision is  to  be  made,  and  the  whole  peritoneal  cavity  thoroughly  flushed 
with  salt  solution  of  a  temperature  of  at  least  105°  F.,  or  even  higher, 
for  it  is  well  to  remember  that  the  temperature  of  the  blood  in  these  pa- 
tients is  often  over  107°  F.,  and  to  obtain  any  stimulant  effect  from  the 
heat  the  solution  should  be  several  degrees  higher.  A  temperature  of  the 
salt  solution  as  hot  as  the  hand  can  comfortably  bear  represents  from 
107°  to  110°  F.  When  the  water  returns  clear  from  all  portions  of  the 
abdomen,  it  has  accomplished  all  that  is  possible;  but  none  of  the  de- 


64  POSTOPERATIVE    TREATMENT. 

pendent  portions  of  the  peritoneal  cavity  must  be  forgotten.  Special 
attention  should  be  paid  to  the  pelvis,  the  suprahepatic  spaces  and  those 
outside  the  colon.  A  long  tube  should  be  carefully  passed  to  each  of  these 
spaces  to  obtain  the  full  cleansing  effect  of  the  stream.  All  easily  loos- 
ened masses  of  fibrin  and  pus  should  be  gently  sponged  off  the  surfaces 
of  the  viscera,  and  so  much  as  possible  of  the  fluid  still  in  the  abdomen 
should  be  absorbed  by  gauze  pads.  It  is  well  to  make  two  counteropen- 
ings,  one  in  either  flank,  through  which  drainage  can  be  made,  and  any 
accumulations  in  the  depressions  outside  the  colon  thus  removed.  The 
choice  of  the  drainage  material  lies  between  gauze  and  rubber  tubes. 
Most  operators  at  the  present  time  incline  to  the  use  of  gauze;  some 
prefer  to  combine  the  two,  using  gauze  wicks  about  the  tube,  but  retain- 
ing the  latter  because  of  the  ease  by  which  the  discharges  can  be  re- 
moved by  occasional  irrigations  without  disturbing  the  dressings  to  any 
extent.  In  any  case  the  material  used  must  be  capable  of  carrying  off 
large  quantities  of  fluid  for  the  first  forty-eight  hours,  as  the  absorptive 
power  of  the  peritoneum  is  so  reduced  by  inflammation  and  the  trau- 
matism of  the  sponging  and  irrigation  that  it  is  utterly  incapable  of  tak- 
ing care  of  the  fluid  secreted. 

Recently  the  suggestion  has  been  made  to  remove  the  intestines  from 
the  abdominal  cavity  and  forcibly  scrub  them  with  gauze  pads  wrung  out 
of  hot  salt  solution.  During  the  process  a  continuous  stream  of  the  same 
fluid  is  to  be  kept  flowing  over  the  exposed  loops,  to  prevent  chilhng  and 
to  wash  away  the  loosened  masses  of  fibrin  and  pus.  Such  a  method  is 
certainly  not  applicable  in  case  of  great  septic  absorption,  and  in  which 
the  diminished  strength  of  the  patient  often  could  not  survive  the  an- 
esthetic. Its  field,  if  any,  is  more  in  those  cases  of  fairly  well-localized 
peritonitis  of  a  low  grade  of  virulence  and  a  tendency  to  produce  large 
quantities  of  fibrin  without  much  general  toxemia,  and  even  in  these 
it  is  unnecessary,  and,  therefore,  to  be  condemned.  Another  method, 
which  has  as  yet  been  little  used,  is  a  continuous  bath.  This  plan  of 
placing  the  patient  in  a  bath  of  sterilized  salt  solution  at  98°  F.,  after 
opening  the  abdominal  cavity,  is  indeed  a  heroic  measure,  but  the 
results  of  its  use  in  cases  of  suppurating  joints  and  other  severe  infections 
would  certainly  warrant  its  trial  in  desperate  conditions.  It  permits  the 
free  escape  of  pus  lying  between  the  coils  of  the  intestines,  and  with  the 
least  traumatism.  Experimentally  it  has  been  found  that  the  peri- 
toneum of  animals  would  perfectly  well  endure  an  exposure  of  two  hours 
in  a  warm  normal  salt  bath  without  serious  change  in  the  lining  en- 


POSTOPERATIVE   COMPLICATIONS.  65 

dothclium.     In  man,  however,  no  very  remarkable  results  have  been 
reported,  probably  because  it  has  only  been  tried  on  moribund  patients. 

The  suture  of  the  incisions  is  rarely  advisable;  it  takes  time  and 
prolongs  the  anesthesia.  The  sides  of  the  wound  can  be  easily  held 
together  by  the  dressings.  In  cases  in  which  the  distention  of  the  in- 
testines is  so  great  that  difficulty  is  experienced  in  returning  tliem  to  the 
abdominal  cavity,  it  is  an  excellent  plan  to  puncture  several  of  the  most 
distended  loops  after  their  removal  from  the  proximity  of  the  incision,  and 
thus  permit  the  escape  of  gaseous  and  fluid  contents.  A  quick  and 
perfect  method  of  accomplishing  this  is  by  making  a  purse-string 
suture  of  three  stitches  at  the  point  selected,  between  which  a  good- 
sized  aspirator-needle  pierces  the  bowel,  relieving  gas  and  liquid  con- 
tents without  contaminating  the  neighboring  parts.  Before  closing 
the  puncture  excellent  results  have  been  obtained  by  injecting  into  the 
lumen  of  the  gut  several  ounces  of  saturated  solution  of  epsom  salts. 
This  promotes  peristalsis,  cannot  be  vomited,  and  thus  carries  off  the 
poisonous  contents  of  the  bowels.  An  enema  of  eight  ounces  of  hot, 
black  coffee  with  an  ounce  of  whisky  should  follow  the  operation. 

The  above  measures  are  recommended  and  adopted  by  many  of  the 
very  best  surgeons,  and  constitute  an  epitome  of  their  latest  writings 
upon  the  subject.  The  plan,  however,  suggested  by  E.  W.  Dwight 
("Medical  and  Surgical  Reports,  Boston  City  Hospital"),  can  be  ac- 
complished in  much  less  time  and  has  proved,  in  the  few  cases  in 
which  we  have  employed  it,  to  be  equally  effective,  and  preferable 
to  the  more  formidable  measures.  The  method  is  as  follows:  An 
incision  is  made  as  directly  over  the  source  of  infection  as  possible — 
a  one-and-one-half  to  two-inch  incision  is  sufficient  for  this  purpose. 
If  the  purulent  fluid  is  found  free  in  the  abdominal  cavity,  no  attempt 
is  made  to  discover  its  source.  Through  the  incision  a  large  glass 
tube,  one  inch  in  diameter  and  twelve  inches  long,  is  introduced. 
Through  this  is  poured  a  large  quantity  of  normal  salt  solution  as  hot 
as  can  be  borne  with  comfort  on  the  back  of  the  hand.  Flushing  is 
kept  up  until  the  fluid  returns  from  all  portions  of  the  peritoneal  canity 
quite  clear.  The  tube  is  then  removed,  the  excess  of  fluid  permitted 
to  escape,  and  three  or  four  gauze  drains  are  placed  in  difl'erent  directions 
in  the  abdomen.  A  very  large  quantity  of  salt  solution  is  used — 20  to 
25  two-quart  bottles  in  a  single  operation.  If  this  method  is  carried 
out  accurately,  it  is  believed  that  the  toxic  dose  is  reduced  to  the 
minimum  with  the  least  traumatism  to  the  peritoneum. 
6 


66  POSTOPERATIVE    TREATMENT. 

The  after-treatment  must  be  sharply  stimulating ;  strychnin  hypoder- 
matically,  in  doses  of  4-^-  to  yV  grain,  can  often  be  given  every  two  hours 
with  great  advantage;  a  little  morphin  may  be  given  advantageously 
if  required  for  pain  or  restlessness.  The  great  advantage  of  the  mor- 
phin is  that  it  allows  the  patient  to  breathe  with  more  freedom,  because  of 
the  fact  that  such  movement  no  longer  causes  pain,  and  thus  permits  the 
free  motion  of  the  diaphragm.  This  is  known  t©  be  one  of  the  most 
potent  factors,  physiologically,  in  promoting  the  flow  of  lymph,  and  hence 
in  absorbing  fluids  from  the  peritoneal  cavity.  An  ice-coil  to  the  ab- 
dominal wall  is  often  exceedingly  grateful  to  the  patient,  and  no  doubt 
relieves  to  a  certain  extent  the  congestion  and  inflammation  of  the  dis- 
eased peritoneum.  Nourishment  is  advised  within  twelve  hours  in 
amounts  as  large  as  the  patient  can  bear.  If  vomiting  continues,  rectal 
feeding  is  substituted.  Should  small  localized  abscesses  subsequently 
develop  in  different  parts  of  the  peritoneal  cavity,  anesthesia  should  then 
be  induced  and  the  abscess  cavities  emptied. 

Summary. — There  are  certain  matters  in  connection  with  the  treat- 
ment of  postoperative  peritonitis  which  must  be  constantly  borne  in 
mind.  There  are  relative  indications.  There  are  comphcations  that 
demand  intervention.  There  are  conditions  where,  in  the  author's 
judgment,  an  operation  offers  the  only  chance,  and  where  the  patient 
will  surely  die  unless  saved  by  surgical  procedures.  Death  may  occur 
in  any  event.  It  must  occur  under  certain  conditions  unless  prompt 
relief  is  afforded. 

The  first  matter  of  importance  in  this  connection  is  that  the  bowels 
must  act  regularly — that  is,  that  they  should  be  open.  With  severe 
abdominal  pain,  nausea  and  vomiting,  excessive  tympanites,  the  in- 
gestion of  but  a  small  quantity  of  nourishment,  which  is  often  exhibited 
in  concentrated  form,  it  is  not  reasonable  to  suppose  that  there  shall  be 
a  free  fecal  discharge  every  day,  but  at  the  same  time  any  indication  of 
obstruction  must  occasion  serious  anxiety.  With  the  bowels  inflamed 
we  should  understand  just  what  may  happen.  The  tympanites  and 
tenderness  may  prevent  our  recognizing  a  volvulus,  an  intussusception,  or 
an  obstruction  caused  by  adhesions.  The  surgeon  must  not  wait  for 
stercoraceous  vomiting:  he  must  be  prepared  to  act  so  soon  as  there  is 
evidence  of  obstruction. 

To  assert  just  what  symptoms  will  warrant  an  operation  is  a  very 
difficult  matter.  If  the  treatment  of  peritoneal  infection  begins  by 
giving  salines,  calomel,  enemas  of  glycerin  and  water,  or  concentrated 


POSTOPERATIVE    COMPLICATIONS.  67 

solutions  of  magnesium  sulfate,  we  usually  succeed  in  evacuating  the 
bowels.  If  we  fail,  it  may  be  necessary  to  flush  the  colon.  If  these 
measures  are  unavailing  and  if  there  is  nausea  and  vomiting,  an  ex- 
ploratory incision  is  indicated,  especially  if  there  is  excessive  tympanites 
which  prevents  the  palpation  of  any  abdominal  tumor  that  might  be 
caused  by  some  form  of  obstruction  or  adhesion.  The  possibilities  of  a 
spontaneous  recovery  when  peritonitis  exists  are  problematic  in  the 
extreme.  Excessive  tympanites  is  seldom  per  se  an  indication  for  sur- 
gical interference.  It  persists  after  all  other  symptoms  have  subsided, 
sometimes  causing  much  inconvenience. 

As  a  matter  of  fact,  the  whole  subject  of  operative  relief  for  peri- 
tonitis may  be  summed  up  in  very  few  words.  If  pus  is  present,  it 
must  be  evacuated;  if  adhesions  cause  obstruction,  or  if  conditions 
prevail  that  make  it  probable  that  their  formation,  or  the  formation  of 
pus,  will  jeopardize  the  patient's  life,  we  must  operate,  and  it  is  well  to 
do  so  without  delay.  Other  conditions  admit  of  a  difference  of  opinion, 
and  the  existing  circumstances  will  determine  our  plan  of  action.  The 
conditions  I  have  mentioned  admit  of  no  controversy.  Consistent  and 
courageous  surgical  aid  is  the  only  thing  to  be  thought  of. 

Postoperative  Bedsores. — Bedsores,  a  form  of  gangrene,  are  the 
result  of  continued  pressure,  and  it  is  very  important  to  remember  this 
when  a  patient  has  to  be  kept  in  one  position  for  a  long  time.  Under 
such  circumstances,  the  parts  subjected  to  pressure  are  very  apt  to  die, 
and  this  is  more  especially  the  case  with  soft  parts  over  long  promi- 
nences, such  as  the  sacrum,  or  those  subjected  to  pressure  against  the 
edge  of  a  splint.     The  gangrene  in  these  cases  is  moist. 

The  treatment  of  bedsores  resolves  itself  into :  {a)  prophylaxis,  (&) 
treatment  when  a  bedsore  is  threatened,  and  (c)  when  it  is  actually 
present. 

(a)  Prophylaxis. — The  essential  points  in  the  prophylactic  treat- 
ment are,  in  the  first  place,  to  avoid  continuous  pressure,  or  so  to  vary 
or  diffuse  it  that  it  shall  not  exert  itself  too  long  or  too  injuriously  on  one 
part;  and,  in  the  second  place,  to  keep  the  skin  dry.  The  first  indi- 
cation is  carried  out  by  frequently  altering  the  position  of  the  patient 
or  the  part,  or  by  so  arranging  matters  that  the  pressure  shall  not  be 
brought  to  bear  on  a  bony  prominence.  For  instance,  the  patient  may 
lie  on  a  ring-pillow,  the  opening  in  the  pillow  being  opposite  the  part 
where  pressure  is  to  be  avoided.  Or  he  may  lie  upon  a  soft  wool  pelt, 
tanned  with  wool  intact. 


68  POSTOPERATIVE    TREATMENT. 

Another  and  in  most  cases  the  best  plan  is  to  place  the  patient 
on  a  water-pillow  or  water-bed,  so  that  the  pressure  does  not  remain 
localized  to  any  one  point,  but  is  distributed  over  a  wide  area.  In  using 
a  water-pillow  care  must  be  taken  that  the  proper  quantity  of  water 
is  introduced;  if  too  much  is  present,  the  pillow  becomes  hard  and 
convex,  and  does  not  adjust  itself  equably  to  the  skin.  On  the  other 
hand,  if  there  is  too  little  water,  the  patient  is  not  properly  supported, 
and  the  part  comes  in  contact  with  the  bed.  Just  sufficient  water 
should  be  put  in  to  keep  the  patient  floating,  and  a  good  method  of 
testing  this  is  to  bear  one's  whole  weight  on  the  pillow  by  pressing  the 
two  spread-out  hands  in  the  center;  if  they  just  touch  the  other  side  of 
the  water-pillow,  the  patient's  body  will  float  when  laid  upon  it.  The 
water  in  the  pillow  should  be  tepid  when  introduced  and  it  ought  to  be 
changed  every  three  or  four  days,  otherwise  it  is  apt  to  become  foul. 
A  large  water-pillow  must,  of  course,  be  filled  upon  the  bed.  The 
pillow  is  covered  by  a  draw-sheet,  and  great  care  should  be  taken  that 
this  is  quite  smooth. 

A  second  point  in  avoiding  bedsores  is  to  see  that  the  parts  most 
exposed  to  pressure  are  kept  dry.  The  patient  should  be  turned  over 
twice  a  day,  and  the  sacrum,  or  any  other  region  subjected  to  pressure, 
should  be  carefully  washed  and  thoroughly  dried ;  and  not  only  dried,  but 
rubbed  gently  with  a  soft  towel  so  as  to  improve  the  circulation  and 
nutrition  of  the  tissues.  It  is  then  dusted  over  with  powdered  boric  acid 
or  talcum  powder. 

(b)  When  a  bedsore  is  threatening,  that  is,  when  the  skin  is  becoming 
red,  the  same  measures  should  be  continued,  but  it  is  well  to  relieve  the 
pressure  entirely  by  placing  a  ring-pillow  around  the  part  on  the  surface 
of  the  water-bed.  In  addition  to  gently  rubbing  the  part  with  a  soft 
towel,  the  circulation  should  be  further  promoted  and  the  epidermis 
hardened  by  the  application  of  some  stimulating  fluid,  such  as  spirits  of 
wine  or  whisky.  The  spirits  of  wine  is  allowed  to  dry  on  the  skin, 
which  is  then  rubbed,  and  subsequently  dusted  with  powdered  boric 
acid.  At  a  later  period,  when  the  skin  is  becoming  raw,  lint  spread  with 
equal  parts  of  balsam  of  Peru  and  resin  ointment  is  a  very  good  appli- 
cation. It  should  be  renewed  night  and  morning,  after  the  part  has 
been  washed,  dried,  and  rubbed  with  alcohol. 

(c)  When  a  bedsore  has  formed,  the  slough,  and  subsequently  the 
sore,  must  be  kept  as  nearly  aseptic  as  possible.  If  the  patient  is  lying 
on  the  part,  it  is  impossible  to  carry  out  one  of  the  chief  principles  in  the 


POSTOPERATIVE    COMPLICATIONS.  69 

treatment  of  gangrene,  viz.,  to  favor  Ihc  drying  of  the  slf^ugh;  and  that 
being  so,  there  is  no  objection  to  the  use  of  antiseptic  ointments,  which 
is,  after  all,  one  of  the  most  valuable  methods  of  keeping  the  affected 
area  aseptic.  The  best  is  the  full-strength  boric  or  eucalyptus  oint- 
ment, changed,  when  the  slough  has  separated,  for  the  quarter-strength 
boric.  Balsam  of  Peru,  either  alone  or  mixed  with  white  of  egg  in  equal 
proportions,  is  also  a  good  dressing.  So  soon  as  possible  the  patient 
should  be  made  to  lie  on  the  side,  when  the  sore  will  usually  begin  to 
heal.  Meanwhile  the  general  nutrition  of  the  patient  should  be 
attended  to  by  the  administration  of  light  and  easily  digested  food 
and  stimulants. 


CHAPTER  IV. 

GENERAL  PRINCIPLES  OF  AFTER-TREATMENT 
AND   POSTANESTHETIC  COMPLICATIONS. 


CHAPTER  IV. 

GENERAL  PRINCIPLES  OF  AFTER-TREATMENT  AND 
POSTANESTHETIC  COMPLICATIONS. 


GENERAL  REMARKS. 

It  would  be  impossible  to  formulate  a  definite  set  of  rules  to  cover 
the  postoperative  management  in  major  and  minor  operations.  Much 
necessarily  is  left  to  the  judgment  of  the  attending  surgeon  and  nurse. 
Some  patients  are  very  susceptible  to  pain ;  others  bear  pain  surprisingly 
well.  Many  are  extremely  restless,  nervous,  or  hysterical;  others  calm, 
stoical,  and  indifferent.  Again,  some  patients  are  pleasant,  considerate, 
and  easily  cared  for ;  others  exacting,  irritable,  and  very  difficult  to  con- 
trol. Tact  and  gentleness  as  well  as  firmness  are  required  for  the  proper 
management  of  these  various  temperaments,  and  it  should  always  be 
borne  in  mind  that  patients  are  entitled  to  every  possible  comfort  or 
assistance,  so  long  as  it  does  not  interfere  with  their  recovery. 

Immediately  after  major  operations,  and  in  minor  cases  in  which 
there  is  evidence  of  shock  or  exhaustion,  and  before  the  patient  is  re- 
moved from  the  operating  table,  a  high  rectal  enema  of  normal  salt  solu- 
tion at  a  temperature  of  iio°  F.  should  be  given,  and,  if  necessary,  a  hy- 
podermatic injection  of  strychnin,  -:^q  to  -jq-  grain,  should  be  administered 
and  the  patient  carefully  and  gently  placed  in  bed.  The  patient  should 
then  be  surrounded  with  warm- water  bottles.  But  the  danger  of  burns 
from  too  close  contact  with  hot- water  bottles  has  not  been  exaggerated; 
they  should  never  be  placed  next  the  patient,  but  wrapped  in  flannel 
cloths  or  placed  outside  of  the  blankets.  The  patient  must  never  be  left 
alone.  A  reliable  nurse  or  attendant  should  remain  with  him  to  guard 
against  accidents  from  vomiting  or  choking  or  prevent  any  act  of  ^•io- 
lence  on  his  part  if  delirious,  and  especially  to  note  any  evidence  of  sud- 
den collapse  which  may  call  for  immediate  measures  of  rehef.  It  is 
also  important  that  the  anesthetist  should  remain  with  the  patient  until 
he  has  recovered  from  the  immediate  eiiects  of  the  anesthetic, 

73 


74  POSTOPERATIVE    TREATMENT. 

It  is  our  custom,  unless  specially  contraindicated,  to  place  the  patient 
upon  the  right  side  (Fig.  4).  This  position  is  also  strongly  recommended 
by  Hewitt  in  the  following  language:  "In  this  position  stertor  at  once 
ceases;  the  tongue  gravitates  to  the  sides  of  the  mouth,  and  a  free  air- 
way is  established;  mucus  and  saliva  are  not  swallowed;  coughing  is 
prevented,  and  should  vomiting  occur,  any  vomited  matter  will  readily 
find  an  escape  without  interfering  with  breathing." 

No  nourishment  whatever  should  be  given  by  the  mouth  for  a  few 
hours  following  anesthesia.  To  relieve  extreme  thirst,  the  frequent 
sipping  of  hot  water  or  tea  is  often  very  grateful  to  the  patient,  and  may 
assist  in  causing  free  emesis,  which  sometimes  tends  to  relieve  the  feel- 
ing of  nausea ;  when  this  does  not  suffice  to  allay  the  thirst,  the  holding 
in  the  mouth  of  a  cloth  or  a  gauze  sponge  dipped  in  cold  water  and 
changed  frequently  may  afford  great,  relief. 

Pallor  and  feebleness  of  pulse  which  follow  anesthesia  are  usually 
associated  with  nausea  and  vomiting.  They  may,  however,  indicate 
approaching  shock,  the  result  of  prolonged  anesthesia  or  cardiac  failure. 
The  head  must  be  kept  low  and  the  patient  warm,  and  quiet,  free  respi- 
ration maintained;  enemas  of  brandy  or  turpentine  with  hot  water 
should  be  given,  and,  in  critical  cases,  artificial  respiration  is  required, 
with  the  hypodermatic  use  of  sulfuric  ether,  10  to  30  minims,  strychnin, 
-g-^Q-  grain,  digitalin,  J^-  grain,  and  brandy,  or,  lastly,  adrenalin  solution. 
In  one  instance  where  there  was  great  cardiac  depression,  the  result 
of  chloroform  narcosis,  prompt  and  complete  recovery  resulted  from 
the  use  of  adrenalin  chlorid  (1:1000)  in  i  ounce  of  warm  normal  salt 
solution  administered  hypodermatically. 

POSTOPERATIVE  POSTURE  OF  THE  PATIENT. 

General  Considerations. — Much  has  of  late  been  written  upon 
the  important  subject  of  posture  or  position  of  the  patient  immediately 
following  operations.  Rest,  bodily  and  mentally,  is  the  first  consid- 
eration. The  patient,  being  placed  in  a  bed  previously  warmed, 
should  be  rendered  as  comfortable  as  possible.  It  seems  to  be  a 
custom  or  fancy,  among  American  surgeons  especially,  that  after 
all  operations  of  severity  the  patients  must  be  placed  in  the  dorsal  or 
recumbent  position,  in  which  uncomfortable  posture  they  are  forced 
to  remain,  not  being  allowed  to  move  or  turn  upon  either  side  for  several 
days. 

Allingham,  of  England,  and  Fowler,  of  New  York,  appear  to  have 


POSTOPERATIVE   POSTURE   OF   THE   PATIENT. 


75 


been  the  first  to  abolish  this  ancient  custom.  Very  few  people  indeed 
sleep  wholly  upon  the  back,  and  when  forced  to  do  so,  are  exceedingly 
uncomfortable.  There  are  many  rational  objections  to  this  position. 
Women  who  are  kept  long  in  this  posture  after  laparotomy  are  very 
liable  to  develop  cystitis  from  inability  to  empty  the  bladder  completely. 
It  has  been  our  custom  for  many  years  to  place  patients  upon  the  right 
side  so  soon  as  placed  in  bed  and  before  they  recover  from  anesthesia. 
This  posture  (see  Fig.  4)  tends  to  prevent  mucus  or  saliva  from  collect- 
ing in  the  mouth  and  fauces,  and  thus  decreases  the  tendency  to  nausea 
and  vomiting.  Later,  if  proper  abdominal  bandages  have  been  applied, 
we  allow  the  patient,  with  the  assistance  of  the  nurse,  gently  to  assume 
whatever  position  is  most  comfortable.  Owing  to  the  prominence  of 
the  sacrum  and  spinal  vertebras,  the  dorsal  position,  if  long  continued, 
is  especially  apt  to  cause  bedsores,  which  is  not  the  least  objectionable 
feature.  The  tendency  also  to  meteorism  or  gaseous  distention  of  the 
abdomen  is  increased  by  the  dorsal  position. 


Fig.  2. — Prone  Position  as  Recommended  by  Allingham. 

Prone  Position. — Allingham,  of  England,  has  pointed  out  the  value 
of  this  position  after  extensive  injury  to  the  extremities  or  larger  arteries. 
Under  such  circumstances  the  integrity  of  the  limb  depends  upon  the 
rapid  development  of  collateral  circulation.  When  it  is  desired  to  drain 
a  wound  opening  upon  the  anterior  surface  of  the  body,  in  abscess  of 
the  appendix,  suprapubic  cystotomy,  etc.,  the  prone  position  is  far  more 
desirable  and  the  patient  finds  it  more  comfortable  than  the  dorsal  posi- 
tion. 

Fowler's  Semi-erect  Position  (Fig.  3). — This  position,  so  ably 
recommended  by  Fowler,  is  appHcable  especially  to  cases  of  appendicu- 


76 


POSTOPERATIVE    TREATMENT. 


lar  abscess,  operations  upon  the  stomach  or  thorax,  septic  peritonitis,  and 
laparotomies  in  general,  particularly  when  the  patient  has  been  exposed 
to  abdominal  infection.  In  this  position  all  fluids  within  the  abdominal 
cavity  gravitate  to  the  lowest  portion,  thus  limiting  the  area  of  possible 


Fig.  3. — Fowler's  Semi-erect  Position. 

infection  and  increasing  the  resisting  powers  of  the  peritoneum.  This 
position  is  far  more  comfortable  than  the  dorsal  posture,  and  admits 
of  greater  freedom  in  breathing,  use  of  the  arms,  etc. 


Fig.  4. — Right  Lateral  Position. 

The  Lateral  Position  (Fig.  4). — The  patient  lies  upon  the  side, 
the  knees  flexed,  with  a  small  pillow  or  pad  between  them,  and  a  pillow 
to  support  the  back.  This  position  is  considered  by  many  to  be  the 
most  comfortable  possible.  The  muscles  of  the  abdomen  are  relaxed, 
relieving  all  tension  upon  the  wound  or  stitches.  Patients  in  this  posi- 
tion urinate  more  readily  and  require  less  attention.     Old  people  and 


POSTOPKRATIVE    NAUSKA    AND    VOMITING.  77 

children  should  be  allowed  greater  freedom  after  oj>eration,  and  if  the 
dressings  are  fixed  with  broad  adhesive  straps,  no  unnecessary  restraints 
need  be  insisted  upon,  except,  possibly,  enforced  quietude;. 

POSTOPERATIVE  NAUSEA  AND  VOMITING. 

General  Considerations. — The  condition  of  the  stomach  prior  to 
anesthesia,  the  kind  of  anesthetic  employed,  duration  of  administration, 
character  or  extent  of  operation,  as  well  as  temperament  of  the  patient, 
all  have  their  influence  upon  postoperative  nausea  and  vomiting.  If 
the  patient  has  not  been  properly  prepared,  and  there  is  solid  or  liquid 
food  remaining  in  the  stomach,  vomiting  will  usually  be  troublesome. 
Thorough  lavage  is  the  best  means  by  which  it  may  be  alleviated.  As 
regards  chloroform,  sulfuric  ether,  and  A.  C.  E.,  and  other  mixtures, 
authorities  agree  that  the  administration  of  ether  is  more  often  followed 
by  transient  retchings,  but  severe,  protracted,  and  dangerous  vomiting 
is  more  common  after  chloroform.  "  Vomiting  after  A.  C.  E.  mixture 
is  usually  slight,  though  sometimes  protracted.  Old  people  are  rarely 
affected  by  after-sickness  from  A.  C.  E.,  even  though  the  administration 
has  been  prolonged.  Billroth's  mixture  of  chloroform  and  ether  has 
been  received  with  great  favor  by  continental  surgeons,  and  is  said  to  be 
rarely  followed  by  vomiting."     (Hewitt.) 

In  all  forms  of  anesthesia  one  of  the  principal  objections  is  the  fact 
that  the  operator  is  led  to  ignore  the  flight  of  time,  to  the  detriment  of 
the  patient.  It  should  always  be  remembered  that  the  shorter  the  oper- 
ation and  the  smaller  the  amount  of  anesthetic  given,  the  better.  The 
patient  once  having  been  anesthetized,  the  rule  to  be  borne  in  mind  is 
the  saving  of  time,  animal  heat,  and  the  amount  of  anesthetic.  Some 
patients  are  more  prone  to  vomit  after  anesthesia  than  others.  Accord- 
ing to  Hewitt,  rosy-cheeked  children,  young  women  of  good  color  and 
full  lips,  and  flabby-looking  individuals  with  an  unhealthy  and  dusky 
appearance  are  much  more  liable  to  postoperative  vomiting  than  others. 
Such  patients  nearly  always  secrete  large  quantities  of  mucus  and  saliva. 
Thin,  spare,  and  sallow  patients,  those  who  have  become  anemic  from 
exhausting  diseases,  and  aged  persons  are  not  often  nauseated  after 
anesthesia.  Patients  of  "bilious"  habit  frequently  suffer  a  good  deal 
after  ether  or  chloroform. 

Lastly,  the  nature  or  extent  of  the  operation  has  its  influence  upon 
the  postoperative  vomiting.  Operations  upon  the  intestines,  oophorec- 
tomy, protracted  laparotomies  in  which  the  bowels  are  exposed  or  freely 


78  POSTOPERATIVE    TREATMENT. 

manipulated,  or  in  which  heavy  metal  retractors  are  used,  predispose 
to  postoperative  sickness  of  more  or  less  intensity. 

Special  Methods  of  Prevention. — It  is  believed  by  good 
authority  that  ^l-o  ^^  yio"  grain  of  atropin  sulfate  given  under  the  skin 
before  etherization  lessens  the  tendency  to  nausea  and  vomiting  ma- 
terially. (Buxton.)  "The  administration  of  oxygen  immediately 
after  the  removal  of  the  anesthetic  is  a  favorite  practice  with  many 
physicians  who  claim  that  the  period  of  recovery  from  the  anesthetic 
is  thereby  shortened,  and  also  that  the  nausea  and  vomiting  are  much 
diminished."  ("International  Text-book  of  Surgery.")  Lewin  says: 
"  The  vomiting  is  frequently  due  to  swallowing  of  the  mucus  and 
saliva  containing  some  of  the  anesthetic  in  solution.  The  anesthetic 
thus  acts  as  a  direct  irritant  to  the  stomach,  and  vomiting  is  induced 
by  the  elimination  of  the  drug  through  the  glands  of  the  gastric 
mucosa."  He  suggests  two  plans  to  prevent  this  local  effect:  (i)  a 
local  anesthetization  of  the  gastric  mucosa,  which  may  be  done  by  lav- 
age of  the  stomach  with  a  solution  of  cocain  of  0.05  gram  to  o.i  gram 
cocain  in  500  grams  water;  (2)  protect  the  gastric  mucosa  from  the 
direct  influence  of  the  anesthetic  by  the  use  of  some  indifferent  sub- 
stance which  will  form  a  coating  over  it.  For  this  purpose  he  suggests 
the  use  of  a  mucilage  of  acacia,  of  tragacanth,  salep,  or  a  thick  decoction 
of  Iceland  moss.  By  changing  the  position  of  the  patient,  all  parts  of 
the  stomach  can  be  reached.     ("Practical  Medicine  Series,"  vol.  ii,  1901.) 

Treatment. — The  patient  should  be  kept  quiet.  If  vomiting  proves 
distressing,  give  a  few  sips  of  simple  hot  water  or  a  small  cup  of  hot  tea. 
I  have  frequently  known  a  draft  of  hot  water  or  tea  to  relieve  distress- 
ing retching.  Hot  coffee  and  champagne  have  also  been  recommended. 
Small  doses  of  cerium  oxalate  or  bismuth  subnitrate,  or  calomel  in  small 
and  frequently  repeated  doses,  have  proved  at  times  highly  beneficial. 
Cold  water  and  ice  should  be  avoided.  In  our  experience  they  only 
tend  to  aggravate  the  trouble.  Sometimes  the  application  of  an  ice- 
pack to  the  epigastrium  will  give  relief.  The  inhalation  of  vinegar  has 
been  of  no  value  in  our  hands.  Buxton  speaks  highly  of  the  use  of  ten 
to  fifteen  grains  of  sodium  bicarbonate  dissolved  in  a  little  hot  coffee. 
In  the  more  aggravated  cases,  lavage  of  the  stomach  with  a  solution  of 
sodium  bicarbonate,  together  with  a  hypodermatic  injection  of  morphin, 
has  proved  more  effective  than  anything  else  we  have  tried.  Linevitch  ad- 
vises washing  out  the  stomach  with  lukewarm  alkaline  solutions.  Blum- 
bul  employs  plain  water  for  the  same  purpose  and  speaks  favorably  of  this 


POSTOPERATIVE    SURGICAL   SHOCK.  79 

treatment.  I  have  lately  tried  lavage  of  the  stomach  with  normal  salt 
solution  containing  i :  1000  solution  of  adrenalin  chlorid  with  very  marked 
success.  If  there  is  a  pronounced  neurotic  element  in  the  vomiting  fol- 
lowing anesthesia,  great  benefit  may  be  derived  from  the  use  of  an  enema 
coinposed  of  one  teaspoonful  of  tincture  of  asafetida  to  one  pint  of  hot 
water.  Potassium  bromid,  twenty  grains  to  two  ounces  of  water,  is 
recommended  by  Hewitt. 

POSTOPERATIVE  SURGICAL  SHOCK. 

General  Considerations  of  Shock. — Some  surgeons  employ  the  term 
collapse  as  synonymous  with  shock;  others  employ  it  to  designate  a  con- 
dition of  shock  produced  by  mental  disturbance  rather  than  physical 
injury.  Crile  regards  collapse  as  an  inhibition  of  the  vasomotor  center, 
in  contrast  to  shock,  which  is  exhaustion  of  the  center.  Pure  collapse 
and  pure  shock  may  possibly  be  distinguished  in  laboratory  experiments, 
but  clinically  the  two  are  usually  so  closely  combined  as  to  render  a  dis- 
tinction impossible,  and,  so  far  as  the  treatment  is  concerned,  they  are 
identical. 

The  etiology  of  surgical  shock  has  never  been  fully  determined  or 
satisfactorily  explained.  The  condition  is  defined  by  Gould  as  a  "  re- 
laxation or  abolition  of  the  sustaining  and  controlling  influences  which 
the  nervous  system  exercises  over  the  vital  organic  functions  of  the  body, 
the  result  of  a  profound  impression  made  on  the  cerebrospinal  axis, 
either  directly  through  the  agency  of  an  afferent  nerve  or  through  the 
circulatory  system." 

According  to  Warren,  "postoperative  shock  is  a  pecuHar  state  of 
reflex  depression  of  the  vital  functions,  especially  of  the  circulatory  sys- 
tem, due  to  nervous  exhaustion  resulting  from  irritation  of  the  peripheral 
ends  of  sensory  and  sympathetic  nerves.  There  is  also,  apparently, 
exhaustion  of  the  medulla  and  spinal  cord  followed  by  marked  lowering 
of  the  vital  powers."  Goltz's  experiments  show  that  exhaustion  or 
paralysis  of  the  vasomotor  centers  in  the  medulla  is  the  essential  feature, 
and  that  this  is  produced  in  a  reflex  manner  by  disturbances  of  the  sen- 
sory nerves.  The  degree  of  shock  is  therefore  dependent  upon  the  se- 
verity of  the  irritation  as  well  as  the  length  of  time  w-hich  this  continues 
in  existence. 

The  above  views  are  in  accord  with  the  consensus  of  modern  opinion, 
but  it  is  of  vast  clinical  importance  to  remember  that  the  diminution 
of  the  blood-supply  alone  or  loss  of  vascular  tone  may  be,  and  often  is, 


So  POSTOPERATIVE    TREATMENT. 

the  most  potent  cause  of  serious  and  fatal  shock;  for  if  sufficient  in- quan- 
tity, the  loss  of  blood  weakens  the  heart-action  and  causes  a  disturbance 
of  the  entire  circulatory  system.  The  nervous  phenomena  in  this  class 
of  cases  is  secondary  to  and  dependent  upon  the  loss  of  the  blood-supply. 

Hewitt  says:  "  In  the  treatment  of  shock,  it  is  well  to  remember  that 
the  symptoms  of  shock  which  appear  during  or  immediately  following 
an  operation  are  often  so  closely  interwoven  with  those  induced  by  toxic 
quantities  of  the  anesthetic  or  those  dependent  upon  asphyxia  that  they 
may  easily  be  attributed  to  other  causes,  or,  conversely,  the  toxic  phe- 
nomena may  be  erroneously  referred  to  surgical  shock."  The  degree  of 
shock  may  range  from  a  mere  temporary  faintness  lasting  but  a  few 
moments  to  a  more  profound  protracted  condition  that  may  eventuate 
in  death.  In  determining  the  character  of  the  shock,  the  condition  of 
the  system  prior  to  the  operation,  or  time  required  to  complete  the  opera- 
tion, should  be  taken  into  consideration. 

Amputation  following  long-continued  suffering  and  depletion  of 
the  system,  especially  after  extensive  compound  fractures  or  infected 
wounds,  double  amputations  or  other  mutilations  following  severe  crush- 
ing injuries,  nephrectomy,  laparotomies  in  general,  in  ileus  or  for  the 
removal  of  large  tumors  with  intestinal  adhesions,  and,  lastly,  operations 
upon  the  brain  and  spinal  cord,  are  especially  liable  to  be  followed  by 
severe  and  prolonged  shock. 

All  operations  should  be  performed  as  rapidly  as  is  consistent  with 
good  surgery.  The  intestines  should  be  exposed  as  little  as  possible, 
avoiding  all  minor  measures  known  to  increase  shock,  such  as  the  use 
of  large  metal  abdominal  retractors,  unnecessary  jarring  of  the  patient, 
the  employment  of  dry,  warm,  sterilized  towels  and  sheets,  instead  of 
those  wet  with  aseptic  solutions  to  isolate  the  field  of  operation.  ("  Medi- 
cal Summary.")  Surgical  shock  may  supervene  at  the  moment  of  first 
incision,  but  in  the  majority  of  cases  it  does  not  appear  until  toward 
the  close  of  the  operation,  or  within  from  one-half  to  two  hours  immedi- 
ately following.  In  rare  instances,  twenty-four  to  forty-eight  hours 
may  elapse,  this  condition  being  termed  "delayed  shock." 

General  Symptoms. — The  ordinary  symptoms  of  postoperative 
shock  in  well-marked  cases  are  about  as  follows:  The  patient 
may  complain  of  chilliness,  have  a  severe  chill,  or  the  symptoms 
may  come  suddenly  without  warning.  The  patient  is  cold,  faint, 
and  trembling,  the  face  is  pale  and  expressionless,  pulse  small  and 
rapid.     The  surface  of  the  body  becomes  moist  with  cold,  clammy  per- 


POSTOPERATIVE   SURGICAL   SHOCK.  »I 

spiration,  the  nervous  system  seems  to  be  profoundly  affected,  the  men- 
tal faculties  show  signs  of  disturbance,  there  may  be  incoherency 
of  speech  or  delirium.  There  is  usually  difficulty  in  breathing,  sighing 
respiration,  and  other  signs  of  prostration.  The  body-temperature 
and  pulse  are  the  best  guides  to  determine  the  severity  of  the  shock,  and 
should  always  be  carefully  noted.  In  the  average  case  the  temperature 
usually  falls  one  or  two  degrees.  A  fall  of  three  or  four  degrees  indi- 
cates a  very  critical  condition,  recovery  being  exceptional. 

Preventive  Measures. — When  the  condition  of  the  patient  or  char- 
acter of  the  operation  is  such  as  to  predispose  to  shock,  or  if  there  be 
sudden  or  unexpected  loss  of  blood,  or  if  from  any  other  cause  we  recog- 
nize symptoms  which  indicate  impending  shock,  preventive  measures 
should  be  adopted  at  once.  Since  the  introduction  of  anesthesia,  the 
severe  forms  of  shock  are  not  so  frequently  seen.  A  simple  and  effi- 
cacious measure  for  preventing  shock  is  the  repeated  administration 
of  brandy  or  whisky  several  hours  preceding  the  operation.  In  cases 
in  which  we  anticipate  shock,  an  ounce  of  whisky  in  six  or  eight  ounces 
of  hot  water,  given  ten  to  twelve  hours  before  the  operation  and  repeated 
once  or  twice  at  intervals  of  two  or  three  hours,  will  usually  secure  a 
full  pulse,  allay  all  previous  fear,  and  render  the  patient  so  susceptible 
to  the  anesthetic  that  but  little  will  be  required.  The  effects  of  this 
stimulant  continue  often  from  ten  to  forty-eight  hours,  and  thereby 
prevent  secondary  shock  and  exhaustion.     (Dennis.) 

In  operations  upon  the  brain,  Dana  believes  that  the  danger  of  shock 
is  lessened  by  getting  through  the  skull  without  the  use  of  mallet  and 
chisel,  yet  Keen  habitually  employs  the  mallet  and  chisel  in  cranial  sur- 
gery, without  increased  fear  of  shock  from  this  source.  Again,  in  cere- 
bral surgery,  as  pointed  out  by  Gushing,  precise  information  upon  the 
arterial  tension  is  of  value  as  indicative  of  approaching  shock.  In  cases 
of  collapse  from  hemorrhage  or  shock,  and  during  the  course  of  severe 
abdominal  operations,  there  is  little  doubt  that  similar  information  will 
be  of  value  to  the  surgeon.  Many  forms  of  apparatus  have  been  de- 
vised to  serve  this  purpose.  The  Riva-Rocci  instrument,  which  has  been 
in  use  since  1896  in  Italy,  and  which  was  introduced  in  this  country  in 
1900,  appears  to  have  fewer  defects  and  more  advantages  than  the  other 
instruments  brought  to  our  attention.  No  special  training  is  necessary 
to  make  observations  with  it,  and  so  far  as  successive  observations  on 
the  same  patient  are  concerned,  its  accuracy  is  probably  sufficient  for 
clinical  purposes.  It  may  be  that  Gushing  takes  an  enthusiastic  view 
7 


82 


POSTOPERATIVE    TREATMENT. 


of  the  matter  in  his  predictions  that  in  appropriate  cases  the  routine 
observations  upon  blood-pressure  will  soon  come  to  occupy  the  same 
relative  position  that  pulse  and  temperature  occupy  at  present.  ("Bos- 
ton Med.  and  Surg.  Jour.") 


Fig.  5. — Cook's  Modified   Riva-Rocci   Apparatus  for  Determining  Blood- 
pressure. 

A.    Hand  bulb  for  counter-pressure.     B.    Distended  bulb.      C.    Rubber  connect- 
ing tuJae. 

General  Considerations  of  Treatment. — The  indiscriminate  use 
of  normal  salt  solution,  strychnin,  morphin,  digitalin,  nitroglycerin,  and 
other  cardiac  stimulants,  which  has  become  a  matter  of  habit  with 
many  surgeons,  is  mentioned  only  to  be  condemned.  The  recent  ex- 
periments by  Crile  and  the  conclusions  which  he  has  drawn  from  a  series 
of  experiments  have  awakened  general  interest.  Crile  believes  that  the 
essential  features  of  surgical  shock  are  the  exhaustion  or  paralysis  of 
the  vasomotor  centers  which  control  the  tone  of  the  peripheral  circula- 
tion. To  the  surgeon  of  to-day,  the  essential  fact  brought  out  by 
Crile's  experiments  is  that  strychnin,  the  stimulant  universally  em- 
ployed in  the  treatment  of  shock,  is  practically  of  no  value,  and  in  pro- 
nounced cases  may  even  increase  the  condition  it  is  intended  to  relieve. 
This  coincides  fully  with  my  personal  experience,  and  I  have  long  since 
discarded  strychnin  in  certain  varieties  of  shock  except  as  a  respiratory 
stimulant. 

For  the  convenience  of  the  student,  and  with  an  effort  to  formulate 
a  more  practical  and  less  incomprehensible  understanding  of  this  im- 


POSTOPERATIVE    SURGICAL   SHOCK.  8;^ 

portant  subject,  and  in  order  that  the  reader  may  have  a  better  conception 
of  the  principles  governing  the  rational  treatment  of  postoperative  shock 
which  the  different  causes  and  conditions  require,  I  have  divided  the 
subject  into  four  distinct  classes:  (i)  surgical  shock  due  to  vasomotor 
depression,  nervous  exhaustion,  or  vital  depression  without  serious  hemor- 
rhage; (2)  shock  as  a  result  of  hemorrhage ;  (3)  postoperative  shock  from 
the  toxic  effects  of  the  anesthetic;  (4)  shock  produced. by  mental  dis- 
turbance— sometimes  denominated  nervous  collapse. 

Surgical  Shock  Due  to  Vasomotor  Depression,  Nervous  Ex- 
haustion, OR  Vital  Depression  Without  Serious  Hemorrhage. — 
The  distinguishing  features  of  this  type  of  postoperative  shock  are:  The 
patient  immediately  or  within  an  hour  or  two  following  the  operation 
passes  into  a  condition  of  more  or  less  profound  prostration.  The  notable 
absence  of  hemorrhage  sufficient  to  account  for  such  condition,  the  disten- 
tion of  the  veins,  cyanosis,  and  the  exclusion  of  possible  narcosis  from  the 
anesthetic  itself,  render  the  diagnosis,  so  far  as  treatment  is  concerned, 
a  matter  of  little  difficulty.  The  temperature  rarely  falls  more  than 
one  or  two  degrees  below  normal  and  the  nervous  symptoms  are  markedly 
prominent.  In  other  words,  shock  not  accounted  for  by  hemorrhage 
or  narcosis  from  the  anesthetic  or  other  obvious  causes,  indicates  gen- 
eral nervous  reflex  depression  or  vasomotor  exhaustion;  the  indications 
for  treatment  must  be  directed  to  arousing  or  restoring  to  its  normal 
condition  the  depressed  nervous  system.  The  patient,  as  in  all  other 
types  of  surgical  shock,  should  be  placed  fiat  upon  his  back,  and  the 
entire  body  wrapped  in  warm  blankets  and  surrounded  on  all  sides  with 
hot-water  bottles. 

We  object  to  the  Trendelenburg  position  in  this  form  of  shock.  The 
patient,  especially  if  plethoric,  when  placed  in  this  position  will  soon 
exhibit  venous  congestion  of  the  face,  which  may  tend  to  aggravate  the 
condition.  Capillary  congestion  of  the  skin  may  be  relieved  by  vigor- 
ous rubbing,  and  cloths  wrung  out  of  hot  mustard- w^ater  may  be  applied 
to  the  precordial  region. 

Treatment  0}  Shock  Due  to  Depression. — Of  all  heart  stimulants  at 
our  command  for  the  adult,  morphin,  |-  grain  combined  with  digitahn, 
gig-  grain  has  proved  in  my  experience  the  most  effectual.  Adrenalin 
chlorid  i :  1000,  as  suggested  by  Crile,  injected  into  the  infracla\icular 
or  submammary  tissues,  in  connection  with  morphin,  has  acted  promptly 
and  satisfactorily  in  the  few  cases  in  which  we  have  used  it.  We  pre- 
fer to  administer  adrenalin  solution  by  the  mouth  (15  to  30  minims  of  a 


84  POSTOPERATIVE    TREATMENT. 

1:1000  solution  every  thirty  minutes  until  reaction  occurs).  I  have 
never  been  favorably  impressed  with  the  effects  of  strychnin  in  these 
cases ;  in  fact,  I  now  seldom  give  it  except  in  combination  with  brandy 
^  to  I  dram,  and  then  only  when  there  is  embarrassment  of  respiration. 
Atropin,  y^-q  grain,  or  spartein,  i  to  ^  grain,  may  be  given  with  advan- 
tage. A  high  enema  of  warm  normal  salt  solution  with  20  to  30 
minims  of  oil  of  turpentine  will  also  prove  of  benefit,  but  hypoder- 
moclysis  or  intravenous  injections  are  usually  not  indicated. 

Shock  as  a  Result  of  Hemorrhage. — This  is  the  most  fatal  form  of 
postoperative  shock,  depending  in  degree  not  solely  upon  the  amount 
of  hemorrhage,  but  complicated  or  increased  by  the  symptoms  of  general 
shock  or  vasomotor  exhaustion  from  the  blood  loss.  It  is  this  class 
of  cases  that  taxes  severely  the  resources  of  the  attending  surgeon. 
Unless  the  loss  of  blood  has  been  very  sudden  or  profuse,  the  symptoms 
of  shock  do  not  develop  as  rapidly  as  one  would  expect.  The  general 
symptoms  are  about  the  same  as  heretofore  described,  except  that  there 
is  a  greater  tendency  to  nausea  and  vomiting,  and  instead  of  venous 
congestion,  we  have  the  pallor  of  anemia.  Respiration  is  usually  feeble 
but  not  embarrassed,  pulse  rapid,  feeble,  of  a  running  character,  or  ab- 
sent at  the  wrist.  There  is  usually  intense  thirst,  temperature  is  at  first 
normal,  but  decreases  with  the  severity  of  the  attack.  The  fact  that 
there  has  been  severe  hemorrhage  will  warrant  the  belief  that  the  loss 
of  blood  is  the  direct  cause  of  the  shock  and  treatment  must  be  in  accord- 
ance therewith. 

Treatment  of  Shock  Caused  by  Hemorrhage. — It  is  in  this  variety  of 
surgical  shock  that  so  many  lives  have  been  sacrificed  by  erroneously 
resorting  to  drugs.  To  rely  upon  strychnin  or  other  heart  stimulants 
is  folly.  The  recognition  of  hemorrhage  or  loss  of  blood  is  vital.  The 
condition  must  be  combated  by  the  retention  of  a  functioning  amount 
of  blood  in  the  brain,  especially  in  the  respiratory  centers.  The  head 
and  shoulders  should  be  promptly  lowered.  The  Nekton  or  Trendel- 
enburg position  is  best  maintained  by  elevating  the  foot  of  the  bed  some 
inches.  Neither  pillow  nor  bolster  should  be  left  under  the  head.  In 
desperate  cases  the  limbs  should  be  raised  nearly  to  a  right  angle  with  the 
body,  and  thus  held.  Instead  of  this,  ordinary  muslin  bandages  may  be 
applied  firmly  to  one  or  all  of  the  limbs,  and  compression  of  the  veins 
and  arteries  maintained  in  this  manner.  Many  lives  could  be  saved  if 
the  more  essential,  if  not  all,  of  these  measures  were  complied  with 
in  the  first  evidence  of  impending  shock  of  this  character.     (Dennis.) 


POSTOPERATIVE    SURGICAL    SHOCK.  85 

Sudden  pallor  with  increasing  pulse-rate  immediately  following  the 
loss  of  blood  indicates  the  approach  of  shock,  and  the  surgeon  in  charge 
should  recognize  at  once  that  the  life  of  his  patient  is  in  danger.  The 
patient  should  be  carried  to  his  bed  and  surrounded,  as  in  all  cases  of 
shock,  with  artificial  heat ;  and  stimulants  by  the  mouth  or  rectum  should 
be  given.  Rectal  enemas  of  hot  water  with  turpentine  act  well.  Sub- 
cutaneously,  whisky,  ether,  atropin,  or  adrenalin  will  prove  beneficial. 
If  the  hemorrhage  has  been  severe,  and  the  condition  of  the  patient  in- 
dicates further  measures,  hypodermatoclysis  of  normal  salt  solution 
is  the  best  treatment.  High  enemas  of  warm  normal  salt  solution 
should  also  be  administered  every  two  or  three  hours,  and  in 
the  more  pronounced  cases  resort  must  be  had  to  intravenous 
saline  injection.  As  the  patient  rallies,  the  retentive  bandages  if 
applied  may  one  by  one  be  removed.  The  limbs  are  then  lowered, 
but  the  dependent  position  is  maintained  until  all  risk  of  syn- 
cope has  passed.  As  occasion  permits,  concentrated  hot  meat  es- 
sence or  milk,  hot  coffee,  tea,  etc.,  must  be  given — liquids  which  when 
absorbed  will  supply  the  heart  with  a  bulk  of  fluid  sufficient  to  go  on 
with  its  function. 

Postoperative  Shock  from  the  Toxic  Effects  of  the  Anes- 
thetic.— Postoperative  shock  attributable  to  the  anesthetic  itself  is  of 
frequent  occurrence,  being  the  result  of  overdosage,  idiosyncrasy,  or  physi- 
cal condition  of  the  patient  from  previous  disease.  The  symptoms  usually 
appear  during  anesthesia,  the  effects  of  the  anesthetic  causing  rapid 
reduction  of  arterial  tension  to  such  a  degree  as  to  cause  cerebral  anemia, 
and  consequently  paralytic  cessation  of  breathing.  (Hill.)  The  toxic 
effects  of  the  anesthetic  may,  however,  continue  twenty-four  to  forty- 
eight  hours  or  longer  following  the  administration  of  the  anesthetic, 
and  it  is  this  postoperative  form  to  which  I  particularly  desire  to  call 
the  attention  of  the  reader.  The  patient  has  the  ordinary  symptoms 
of  shock,  but  of  a  milder  type.  Respiration  is  always  more  or  less  em- 
barrassed, pulse  slow,  feeble,  irregular,  or  intermittent.  The  symptoms 
characteristic  of  this  form  of  shock  are:  Delayed  resolution,  embar- 
rassed respiration,  frequently  of  the  Cheyne- Stokes  character,  depressed 
circulation.  These,  in  the  absence  of  hemorrhage,  and  especially 
if  this  condition  follows  a  minor  operation,  make  the  diagnosis  of 
toxemia  from  the  anesthetic  certain. 

Illustrative  Case. — W.  H.,  tailor,  aged  twenty-two,  of  slender  build  and 
nervous  temperament,  had  a  slight  cough,  heart-sounds  and  chest  expansion 


86  POSTOPERATIVE-  TREATMENT, 

good,  pulse  72, respiration  normal.  Operation  8  A.  M. — paraphimosis.  Chloro- 
form was  administered  on  Skinner's  mask,  anesthetic  cautiously  given. 
When  about  to  commence  the  operation,  the  breathing  ceased,  and  the  face 
suddenly  became  livid  in  color  and  covered  with  perspiration,  hands  and 
limbs  cold,  pulse  imperceptible  at  wrist.  The  legs  and  body  were  at  once 
elevated,  and  an  attempt  to  establish  artificial  respiration  rapidly  made. 
A  subcutaneous  injection  of  sulfuric  ether  was  given,  and  amyl  nitrite 
applied  to  the  nostrils;  the  patient's  lips  were  occasionally  rubbed  briskly 
with  a  towel,  as  recommended  by  Hewitt.  After  prolonged  exertion, 
respiration  returned,  and  the  wrist  pulse  gradually  reappeared,  although  at 
no  time  normal.  The  operation  was  then  performed  rapidly.  The  patient 
removed  to  his  bed,  and  head  kept  low.  The  conjunctival  reflex  was 
present,  though  very  sluggish.  Respiration  continued  very  slow  and  of  a 
Cheyne-Stokes  character.  Brandy  was  given  by  the  rectum,  and  strychnin 
hypodermatically,  also  oxygen  by  inhalation.  The  patient  remained  prac- 
tically in  this  haK-conscious  condition  for  fully  thirty-six  hours;  during  this 
time  and  for  several  days  immediately  following  there  was  difficulty  in 
swallowing,  and  nourishment  had  to  be  administered  by  the  rectum.  At  no 
time  was  there  nausea  or  vomiting.  Resort  to  artificial  respiration  was 
repeatedly  necessary.     The  ultimate  result  was  recovery. 

Treatment  of  Shock  Caused  from  Anesthetization. — I  have  been  thus 
explicit '  for  the  reason  that  I  have  found  these  cases  constantly  over- 
looked, though  of  quite  frequent  occurrence.  The  treatment  for  this 
class  is  that  already  mentioned  for  surgical  shock  due  to  vasomotor 
depression,  viz.:  partial  inversion,  artificial  respiration,  inhibition  of 
oxygen,  and  application  of  warmth,  etc.  If  the  patient  is  thin,  feeble, 
and  anemic,  the  intravenous  introduction  of  saline  fluid,  or  hypoder- 
moclysis,  with  strychnin,  adrenalin,  or  digitalin,  is  indicated.     (Hewitt.) 

Shock  Produced  by  Mental  Disturbance. — Neurotic  and  alco- 
holic patients,  or  those  of  a  very  timid  character,  especially  females  and 
children,  even  after  trivial  operations,  frequently  exhibit  all  the  phenomena 
of  pronounced  surgical  shock.  Fortunately,  fatal  cases  are  exceedingly 
rare,  the  usual  t)^e  being  mild  and  transient  in  character.  Excessive 
joy,  grief,  anger,  or  fear,  may  give  rise  to  prostration  varying  in  severity 
like  that  of  traumatic  or  surgical  origin.  The  introduction  of  a  sound 
into  the  urethra  has  been  followed  by  death  in  a  few  hours,  and  the  in- 
troduction of  an  aspirating  needle  into  a  pleura  filled  with  fluid  has  been 
followed  by  immediate  death.  So  has  the  opening  of  an  abscess  of  the 
finger.  Relaxation  of  the  sphincters,  polyuria,  or  induction  of  pro- 
fuse diarrhea  may  be  cited  as  instances  of  psychic  shock  from  mental 


GENERAL  POSTOPERATIVE   CONDITION.  87 

or  emotional  causes.  The  state  of  mind  at  the  time  of  the  operation 
influences  materially  its  effects  upon  the  nervous  system,  and  as  the 
sensibility  of  pain  varies  greatly,  so  will  the  postoperative  shock.  In 
the  language  of  Jordan,  "Where  nerve  force  is  predominant,  shock  also 
becomes  predominant,"  It  is  characteristic  of  this  variety  of  shock 
that  it  is  often  late  in  developing.  The  diagnosis  is  ordinarily  easy 
in  the  presence  of  restlessness  and  excitability,  the  characteristic  ex- 
pression of  the  face,  especially  in  children,  in  the  absence  of  hemorrhage 
or  anesthetic  narcosis,  and  especially  when  we  have  reason  to  believe, 
from  the  character  of  the  operation,  that  the  nature  of  the  shock  must 
of  necessity  be  of  neurotic  origin.  I  have  never  seen  a  fatal  case  of 
postoperative  shock  as  the  result  wholly  of  psychic  causes.  Travers, 
however,  describes  cases  of  this  character  which  he  characterizes  as 
"shock  or  prostration"  with  excitement;  the  patient,  while  conscious- 
ness lasts,  is  wild  with  anxiety,  changing  his  position  and  struggHng 
for  air  or  breath,  and  oblivious  to  everything  but  his  impending  fate. 
Usually  delirium  of  a  muttering  or  violent  kind  supervenes,  and  the 
scene  ends  in  coma.  This  form  of  surgical  shock  is  frequently 
encountered  in  excessive  drinkers,  and  in  the  wards  of  our  public 
hospitals.  It  is  seen  in  fully  one-fourth  of  the  fatal  cases  of  shock. 
(Hare.) 

Treatment  of  Psychic  Shock. — If  the  disturbance  is  chiefly  mental,  the 
patient,  especially  if  a  child,  will  usually  rally  speedily  if  spoken  to  in  a  kind 
and  cheerful  manner.  The  principles  already  enunciated  in  the  treatment 
of  the  first  class  of  postoperative  shock  are  applicable  to  this  kind.  All 
active  measures  or  excitement  should  be  avoided,  and  rest  and  perfect 
quiet,  as  far  as  possible,  should  be  enforced.  Rectal  injections  of  tinc- 
ture of  asafetida  one  dram  to  a  pint  of  hot  water,  or  twenty  to  thirty 
grains  of  potassium  bromid  every  two  or  three  hours,  are  highly  recom- 
mended in  shock  of  this  character.  The  alleviation  of  pain  with  mor- 
phin,  -^'  to  I  grain,  preferably  combined  with  atropin,  is  frequently 
necessary  and  tends  to  hasten  reaction. 

GENERAL  POSTOPERATIVE  CONDITIONS. 

Acute  dilatation  of  the  stomach  is  a  condition  which  sometimes 
follows  prolonged  administration  of  an  anesthetic,  and  when  accom- 
panied with  shock  may  cause  grave  symptoms,  which  if  not  promptly 
relieved  may  speedily  terminate  in  death.  I  have  been  astonished  at 
the  frequency  with  which  dilatation  occurs,  and  yet  this  fact  has  not  been 


88  POSTOPERATIVE    TREATMENT. 

recognized  or  noted  by  writers  upon  this  subject,  so  far  as  I  have  been 
able  to  ascertain.  The  symptoms  usually  make  their  appearance  from 
eight  to  twelve  hours  after  anesthesia.  In  patients,  as  a  rule,  who  have 
not  vomited,  dilatation  comes  on  rapidly,  pressure  of  the  dilated  stomach 
causing  marked  distress  and  disturbance  of  the  heart,  the  lungs,  and 
the  portal  circulation.  Dyspnea  and  palpitation  of  the  heart  are  promi- 
nent symptoms,  and  increase  according  to  the  extent  to  which  the  dia- 
phragm is  forced  upward  by  the  stomach  distended  with  gases.  If  this 
condition  continues  uninterrupted,  the  intestines  become  involved  until 
there  is  a  general  condition  of  paresis  with  symptoms  of  tetany.  Tabes 
facialis  is  marked  and  the  pulse  is  greatly  increased.  Temperature 
may  be  but  slightly  elevated,  normal,  or  subnormal.  Palpation  readily 
reveals  the  trouble,  there  being  marked  resonance  over  the  stomach, 
chest  and  colon — so  marked,  indeed,  as  to  be  audible  for  some  distance 
from  the  patient. 

The  following  case  of  recent  occurrence  is  typical  of  the  condition : 
Mrs.  B.,  aged  thirty-four,  medium  height,  well  nourished,  weight  about 
145  pounds,  blond.  Operation  8  A.  M.  A  large  fibroid  tumor  involving  both 
ovaries  was  removed.  The  tumor  was  adherent  to  the  bladder  and  a  portion 
of  the  small  intestines.  The  anesthetic  used  was  Squibb's  ether;  length  of 
administration,  one  hour  and  thirty-seven  minutes.  The  patient  took  the 
anesthetic  well;  no  vomiting;  normal  salt  solution  administered  by  the  rec- 
tum at  the  close  of  the  operation.  The  patient  rallied  well,  shock  not 
marked,  but  complained  of  great  thirst,  which  was  controlled  by  sips  of 
hot  water.  At  2  p.  m.  she  declined  the  hot  water,  complaining  of  dis- 
tress in  her  stomach.  At  6  p.  M.  she  vomited  profusely  and  felt  very  much 
reUeved.  I  was  called  again  at  11.30  p.  M. ;  found  the  patient  in  great  dis- 
tress, pulse  140,  temperature  97.6.  Dyspnea  was  pronounced;  the  patient 
was  very  restless,  could  not  he  down,  face  pale  and  haggard,  marked 
tympanites  over  entire  chest  and  stomach,  slight  twitching  of  facial  muscles 
and  muscles  of  forearm  and  fingers,  forehead  cold  and  clammy,  apparently 
in  a  serious  condition.  Upon  the  introduction  of  the  stomach-tube  gas 
escaped  in  large  quantities.  A  warm  solution  of  sodium  bicarbonate  was 
used,  the  stomach  thoroughly  washed  out,  and  morphin,  j  grain,  with  digi- 
talin,  -g^Q-  grain,  administered  hypodermatically.  Relief  was  immediate  and 
permanent. 

Postoperative  Thirst. — Postoperative  thirst  is  a  matter  of  great 
annoyance  to  the  patient,  in  fact,  frequently  causing  distress  more  diffi- 
cult to  bear  than  pain  itself.  DaCosta  and  Kalteyer  have  shown  that 
directly  after  anesthesia  the  watery  elements  of  the  blood  are  diminished. 


GENERAL   POSTOPERATIVE   CONDITION,  89 

This  result  is  peculiar  to  chloroform  and  ether  when  intnxluced  into 
the  blood  either  by  inhalation  or  by  injection;  they  also  retard  the  oxy- 
gen-carrying elements  of  the  blood  and  have  a  direct  effect  upon  the 
nerves  and  cerebrospinal  centers,  impairing  both  in  direct  ratio  to  the 
amount  of  anesthetic  used.  Postoperative  thirst  is  therefore  nearly 
always  the  direct  result  of  the  anesthetic,  and  this  condition  is  iricreased 
in  proportion  to  the  amount  of  blood  lost  during  the  operation.  Pro- 
longed anesthesia  and  loss  of  blood  are  the  prime  factors  in  causing 
this  most  unpleasant  after-symptom,  and  in  our  experience  the  thirst 
following  ether  is  greater  and  more  prolonged  than  after  chloroform 
administration. 

To  overcome  or  prevent  postoperative  thirst  has  been  a  subject  of 
inquiry  for  a  long  time.  It  is  our  custom  always  to  wash  out  the  stomach, 
after  which  a  high  rectal  enema  of  warm  salt  solution  is  given.  This 
procedure  is  universal  after  all  major  operations,  and  before  the  patient 
is  removed  from  the  operating  table.  This  is  done  not  only  to  prevent 
shock  and  to  stimulate  the  system,  but  to  relieve  postoperative  thirst. 
I  have  often  noted  after  laparotomies  in  which  flushing  of  the  abdominal 
cavity  with  hot  sterile  water  is  done,  and  especially  when  the  major  part 
of  the  fluid  is  allowed  to  remain,  that  the  respiration  and  pulse  usually 
improve  and  postoperative  thirst  is  greatly  lessened.  After  the  patient 
has  partly  regained  consciousness,  the  occasional  sipping  of  hot  water 
will  frequently  give  relief  or  allay  the  extreme  thirst,  but  cold  water  even 
in  small  quantities  invariably  causes  violent  retching  and  vomiting. 
If  the  hot  water  does  not  sufifice,  a  little  champagne,  hot  tea  or  coffee, 
or,  lastly,  the  holding  of  cold  wet  cloths  in  the  mouth,  or  frequently  bath- 
ing the  lips  and  rinsing  out  the  mouth  with  cold  water,  may  suffice  for 
the  first  six  or  eight  hours,  after  which  time,  if  all  tendency  to  vomiting 
or  retching  has  ceased,  a  trial  of  a  few  sips  of  cold  water  may  be  given ; 
if  successfully  retained,  this  may  be  increased  until  the  patient's  wants 
in  this  respect  are  satisfied. 

Of  the  new  remedies  suggested  for  the  relief  of  postoperative  thirst, 
chloretone  seems  destined  to  become  the  most  popular.  A  five-grain 
capsule  given  one-half  hour  before  anesthesia,  followed  by  a  three-grain 
capsule  as  soon  as  the  patient  regains  consciousness,  has  proved  ver)'  suc- 
cessful in  the  few  cases  in  which  we  have  used  it,  but  in  our  experience 
there  is  no  remedy  equal  to  lavage  of  the  stomach  repeated  as  often  as 
required. 

Postoperative  Use  of  Morphin. — The  judicious  use  of  moiphin, 


90  POSTOPERATIVE    TREATMENT. 

hypodermatically  administered,  is  of  inestimable  postoperative  value  in 
nearly  all  major  cases.  I  am  v^ell  aware  that  many  celebrated  surgeons 
denounce  the  use  of  morphin  in  any  form,  asserting  that  it  stops  peri- 
stalsis, locks  up  the  secretions,  increasing  thereby  the  danger  of  infec- 
tion, and  greatly  augments  the  death-rate.  Neither  actual  facts  nor 
clinical  history  warrant  such  assertions. 

It  has  been  my  experience  that  morphin  is  frequently  indispensable 
not  only  to  relieve  acute  postoperative  pain,  but  for  the  relief  of  exhaus- 
tion or  general  nervous  restlessness  which  frequently  follows  prolonged 
operations.  I  have  seen  numerous  instances  in  which,  after  even  an 
ordinary  laparotomy,  the  patient  became  exhausted,  nervous,  or  rest- 
less, with  or  without  acute  pain;  the  heart-action  became  rapid  and 
the  temperature  rose  to  102°,  103°  F.,  or  higher.  In  such  cases  a  hypo- 
dermatic injection  of  ^  to  ^  grain  of  morphin  produces  a  quiet, 
refreshing  sleep,  from  which  the  patient  often  awakes  with  a  normal 
temperature  and  pulse-rate. 

Indications 'f or  the  Use  of  Morphin. — No  fixed  rule  governing 
the  postoperative  use  of  morphin  is  possible.  It  should  be  adminis- 
tered only  when  actually  necessary,  and  subsequently  repeated  as  in- 
frequently as  possible.  No  morphin  should  be  given,  as  a  rule,  until 
the  patient  has  fully  recovered  from  the  immediate  effects  of  the  anes- 
thetic, and  the  mouth,  throat,  and  air-passages  are  free  from  mucus 
and  saliva.  During  the  period  of  reaction  pain  is  frequently  acute,  but 
usually  transient  in  character,  hence  morphin  should  be  withheld.  If 
later  the  patient  suffers  severely  or  is  very  restless,  |-  to  J  grain  of 
morphin,  if  given  subcutaneously,  will  afford  great  comfort  to  the 
patient.     Larger  doses  may  be  needed  in  exceptional  cases. 

The  susceptibility  of  the  patient  to  the  drug  or  peculiar  idiosyncrasy 
should  be  borne  in  mind.  Morphin  is  especially  indicated  after  ampu- 
tations following  severe  crushing  injuries  or  in  severe  postoperative  pain 
of  any  character,  and  especially  after  removal  of  the  ovaries  or  a  hysterec- 
tomy, in  which  the  pain  which  follows  is  sometimes  excruciating.  The 
use  of  morphin  in  conjunction  with  digitalin  in  my  hands  has  proved 
of  greater  service  as  a  heart  stimulant  than  strychnin  or  nitroglycerin. 
In  postoperative  hysteria  or  extreme  restlessness  from  any  cause  the 
modifying  influences  brought  about  by  morphin  will  be  sufficiently  ob- 
vious. The  supposed  ill  effects  caused  by  morphin  checking  the  secre- 
tions or  inhibiting  peristalsis,  etc.,  may  be  partly  overcome  by  combin- 
ing strychnin  with  the  morphin.     The  administration  of  morphin  must 


GENERAL    POSTOPERATIVE    CONDITION.  •  (J I 

be  watched  with  care  and  the  drug  given  only  in  sufficic-nt  quantity  lo 
accomphsh  the  purpcjse  intended. 

Surgeons  are  too  prone  to  early  medication  and  feeding  after  opera- 
tion. Dr.  Joseph  Price  says :  "  Fuss  and  feathers  and  meddlesome  man- 
agement are  foolishness.  Quiet,  absolute,  on  the  back,  with  nothing  for 
twenty-four  hours  but  those  httle  attentions  from  a  skilled  nurse  to  re- 
lieve irksomeness,  to  provide  a  cool  back,  well-rubbed  limbs,  an  empty 
bladder,  a  fresh  mouth  by  rinsing,  with  no  opium  in  the  house,  will  give 
a  cheerful  and  comfortable  patient.  It  should  be  noted  that  patients 
with  the  opium  habit  are  highly  deceitful,  untruthful,  and  are  to  be 
managed  by  the  individual  skill  of  the  operator." 


CHAPTER  V. 

TREATMENT  OF  ASEPTIC  AND   SEPTIC 
WOUNDS. 


CHAPTER  V. 
TREATMENT  OF  ASEPTIC  AND  SEPTIC  WOUNDS. 

Postoperative  Treatment  of  Wounds. — The  after-treatment  of 
wounds  depends  somewhat  upon  whether  they  are  aseptic  or  septic,  and 
in  either  case  their  care  deserves  close  attention  to  detail.  Operative 
wounds  are  rarely  infected  if  only  reasonable  care  is  taken  at  the  time 
of  the  operation.  In  the  changing  of  dressings  the  surgeon  and  his 
assistants  should  always  observe  the  same  care  and  aseptic  regulations 
that  they  do  when  about  to  perform  a  surgical  operation.  Before  the 
wound  is  exposed,  and  before  the  deeper  dressings  are  removed,  the 
bedding  and  underclothing  should  be  covered  with  sterile  towels  and 
excluded  from  possible  contact  with  the  wound.  The  patient's  hands 
must  be  carefully  watched  or  placed  where  they  may  do  no  harm ;  the 
instruments  and  dressing  materials  must  be  in  perfect  condition.  Ar- 
ticles such  as  bowls,  irrigators,  syringes,  etc.,  should  be  absolutely  free 
from  infection. 

The  dressings  of  aseptic  wounds,  unless  loosened  or  soiled,  need 
not  be  changed  until  the  time  has  arrived  for  the  removal  of  the  stitches, 
or  seven  to  nine  days  after  the  operation.  Incisions  upon  the  face,  neck, 
or  hand  heal  much  more  rapidly.  The  dressings  and  part  of  the  sutures 
may  be  removed  the  second  or  third  day.  When  there  is  great  tension  of 
the  skin,  in  large  or  ragged  wounds,  the  stitches  may  be  left  ten  to  four- 
teen days,  especially  if  the  skin  around  the  wound  does  not  appear  well 
nourished  or  the  scar  firm.  Some  surgeons  are  in  the  habit  of  changing 
the  dressings  the  second  or  third  day  follow^ing  the  operation.  This 
is  ordinarily  unnecessary,  and  only  tends  to  annoy  the  patient.  If, 
however,  at  any  time  the  dressings  are  soiled,  or  if  during  the  repair 
or  healing  of  the  wound  the  patient  should  become  chilly  or  have  a 
rigor,  or  if  there  is  pain,  general  restlessness,  or  sudden  rise  of  tem- 
perature, the  dressings  should  be  immediately  removed,  and  the  wound 
carefully  inspected.  If  the  wound  is  found  infected  and  inflamed,  a 
sufficient  number  of  stitches  should  be  removed  to  admit  of  the  free 
escape  of  pus  if  present,  and  relieve  the  tension  of  the  skin.  No  anti- 
septic irrigation  should  be  attempted  at  this  time.     The  skin  and  surface 

95 


g6  POSTOPERATIVE    TREATMENT. 

wound  should  be  cleansed  with  a  solution  of  hydrogen  dioxid,  or  the 
wound  may  be  gently  irrigated  with  a  hot  solution  of  sterilized  normal 
salt  solution.  ■  (For  the  treatment  of  more  pronounced  infection,  cellu- 
litis, erysipelas,  or  septicemia,  the  reader  is  referred  to  articles  upon 
these  special  subjects.) 

In  amputations,  or  following  septic  operations,  when  drainage  is 
expected  or  abundant,  the  dressings  may  require  to  be  changed  in 
twelve  to  twenty-four  or  forty-eight  hours.  Dressings  should  be  re- 
moved when  soiled,  regardless  of  time,  and  changed  as  often  thereafter 
as  indications  seem  to  warrant.  After  dressing  of  pus-cavities  or  open 
wounds,  if  packed  with  gauze,  especially  appendicular  abscesses,  it  is 
little  less  than  cruelty  to  attempt  the  removal  of  the  gauze  in  less  than 
four  to  six  days,  when  adhesions  form  and  the  gauze  will  become  loose, 
admitting  of  painless  removal  and  repacking.     In  aseptic  wounds  the 


Fig.  6. — Andrews'  Scissors. 

dressings  should  be  removed  in  from  seven  to  nine  days,  and  if  the  gauze 
adjacent  to  the  incision  adheres,  it  is  best  to  soak  it  well  with  hydrogen 
dioxid  before  removing  it,  the  wound  being  immediately  recovered  with 
a  clean  piece  of  gauze.  If,  now,  the  wound  appears  to  be  thoroughly 
healed,  the  stitches  may  be  removed.  The  stitches  are  cut  close  to  the 
skin  upon  one  side  below  the  knot,  and  if  of  silkworm-gut,  by  twisting 
gently  and  by  following  the  curve  of  the  stiff  suture,  their  removal  will 
cause  very  little  pain.  The  removal  of  deep-seated  or  imbedded  sutures 
is  greatly  facilitated  by  means  of  Andrews's  scissors  (an  ingenious  inven- 
tion of  Dr.  Frank  Andrews,  of  Chicago).  The  employment  of  these 
enables  the  surgeon  with  a  little  practice  to  grasp  the  knot  firmly  and 
sever  but  one  side  of  the  suture  below  the  tie.  It  is  sometimes  advisable 
not  to  remove  all  the  stitches  at  one  time.  If  all  the  stitches  are  removed, 
and  if  the  wound  is  found  to  be  dry,  firm,  and  healthy  in  appearance,  a 
piece  of  dry  gauze  the  required  shape  and  size  should  be  placed  over  the 


TREATMENT    OF    ASEPTIC    AND    SEPTIC    WOUNDS.  97 

entire  wound  and  the  whole  fixed  with  flexible  c(;IIorlion.  ShouhJ  there 
be  any  gaping  of  the  skin  wound,  the  edges  should  be  drawn  together 
with  small  strips  of  sterilized  zinc  oxid  adhesive  plaster,  and  the  wound 
dressed  as  before. 

After-treatment  of  the  Wound. — Sir  Frederick  Treves  says 
("Operative  Surgery,"  vol.  i): 

"Immense  progress  has  been  made  of  late  years  in  the  treatment  of 
wounds.  In  this  progress  the  most  prominent  figure  is  that  of  Lord 
Lister.  To  him  belongs  the  honor  of  having  effected  a  reformation  in 
surgery,  of  having  established  upon  a  new  and  scientific  basis  the  an- 
cient art  of  healing,  of  having  freed  the  operator  from  the  more  grievous 
of  the  dangers  which  surround  him,  and  of  having  greatly  extended 
the  powers  and  possibilities  of  the  surgeon's  art. 

"As  to  the  exact  method  of  dressing  a  wound,  and  the  materials  to  be 
used  in  that  dressing,  it  is  impossible  to  be  dogmatic. 

"Probably  at  no  time  have  the  modes  of  dealing  with  wounds  been 
more  numerous,  nor  has  the  application  of  a  few  common  principles 
been  more  diverse. 

"All  surgeons  endeavor  to  secure  that  the  wound  shall  be  quite 
clean;  shall  be  aseptic;  shall  not  be  irritated;  shall  be  kept  at  rest. 
One  surgeon  accomplishes  these  ends  in  one  way,  another  in  another,  and 
the  results  are  equal.  He  who  considers  that  his  method  of  dealing  with 
a  wound  is  the  most  perfect  will  find  that  his  neighbor,  who  adopts  very 
different  details,  obtains  an  identical  measure  of  success.  New  anti- 
septic agents  appear  from  time  to  time  upon  the  scene.  They  are  pur- 
sued, are  vaunted  as  perfect,  are  diligently  employed,  and  then  not  a 
few  of  them  fade  away,  some  very  gradually,  others  with  the  suddenness 
of  the  South  Sea  Bubble. 

"In  the  after-treatment  of  the  operation  wound  the  part  must  be  kept 
absolutely  at  rest.  Mere  confinement  in  bed,  with  the  support  of  a 
proper  pillow,  may  suffice  to  effect  this,  or  a  special  splint  or  retentive 
apparatus  may  be  employed.  The  part  is  kept  raised,  so  that  the  cir- 
culation of  the  blood  through  it  may  be  as  much  relieved  as  possible, 
and  is  so  placed  that  drainage,  if  arranged  for,  may  be  readily  eft'ected. 
The  wound  itself  is  simply  dusted  with  iodoform,  and  is  covered  with  a 
thick  layer  of  dry,  sterilized  wool.  Next  to  the  skin  a  layer  of  Till- 
mann's  sterilized  paper  dressing  is  applied,  for  the  excellent  reason 
that  it  never  sticks  to  the  wound.  A  bandage  is  then  so  applied  as  to 
bring  pressure  to  bear  upon  the  wound.     The  eft'ect  of  this  is  that  the 


98  POSTOPERATIVE    TREATMENT. 

edges  of  the  incision  are  kept  well  together,  the  cavity  of  the  wound 
is  obliterated,  any  tendency  to  oozing  is  prevented,  the  use  of  a  drain- 
age-tube is  rendered  unnecessary,  and  the  parts  concerned  in  the  wound 
are  kept  perfectly  at  rest. 

"The  'domet'  bandage  is  best  suited  for  the  majority  of  cases.  The 
bandages  used  are  often  unnecessarily  thick,  and  hence  in  hot  weather 
uncomfortable.  Those  made  of  thin  '  butter-cloth'  muslin  are  very  light 
and  cool.  For  fixing  dressings  on  the  head,  neck,  and  many  other  parts 
they  cannot  be  surpassed.  There  should  be  a  liberal  covering  of  wool, 
as  it  tends  to  equalize  and  diffuse  the  pressure  employed.  The  amount 
of  pressure  employed  must  depend  upon  the  circumstances  of  the  in- 
dividual case.  Unlimited  pressure  would  obviously  not  be  employed  in 
cases  in  which  the  vascular  supply  of  the  part  is  slight  and  the  patient 
very  old.  In  certain  regions — e.  g.,  the  groin — one  or  more  turns  of 
elastic  webbing  bandage  over  the  ordinary  one  will  be  found  useful  for 
maintaining  even  pressure. 

"For  the  last  ten  years  (as  recommended  by  certain  American  sur- 
geons) I  have  made  a  practice  of  keeping  the  wound  absolutely  dry  from 
beginning  to  end.  Microorganisms  cannot  grow  without  moisture,  and 
moist  dressings  and  washing  of  the  wound  provide  this  medium.  To 
illustrate  the  matter  by  an  abdominal  incision,  the  procedure  is  as 
follows:  The  operation  area  is  surrounded  by  hot,  dry,  sterilized  towels. 
The  sponges  used  are  artificial  sponges  made  from  gauze,  which  are 
almost  free  of  moisture. 

"After  the  sutures  are  introduced  the  wound  is  dried,  dusted  with 
iodoform,  and  covered  with  a  thick  dry  dressing  of  cotton-wool  and 
Tillmann's  paper.  The  bandage  or  binder  is  applied  firmly.  The 
wound  is  dressed  again  on  the  fourth  or  fifth  day.  The  dry  dressing 
falls  off,  and  by  means  of  dry  forceps  the  wound  is  cleared  of  the  caked 
iodoform  powder  and  little  dried  blood  which  cover  it.  As  a  matter  of 
fact,  the  forceps  will  'clean'  such  a  wound  quicker  and  more  efficiently 
than  a  prolonged  washing. 

"Iodoform  and  another  dry  dressing  are  again  applied,  and  from 
the  perfectly  dry  wound  the  sutures  are  removed  on  the  eighth  to  the 
tenth  day.  In  my  experience  no  method  of  dealing  with  wounds  has 
given  such  uniformly  successful  results  as  this.  The  simpler  wounds, 
such  as  those  following  the  ligature  of  an  artery  or  the  removal  of  a  small 
growth,  need  not  be  disturbed  for  a  week.  If  much  oozing  be  anticipated 
in  any  case,  the  wound  may  be  dressed  at  the  end  of  twenty-four  hours, 
and  then  left  for  four  or  five  days. 


TREATMENT    OF   ASEPTIC   AND    SEPTIC   WOUNDS.  ()() 

"Sterilized  gauze  or  gauze  charged  with  mercury  };icyanirl  is  used 
very  widely  as  a  dressing,  and  answers  admirably.  It  is  the  rarest 
thing  to  see  any  irritation  of  the  skin  produced  by  the  cyanid,  but  the 
results  from  the  use  of  simple  sterilized  gauze  seem  to  prove  that  the 
antiseptic  is  unnecessary  provided  all  other  precautions  are  taken. 

"Tillmann's  'paper  dressing'  or  'dressing  linen,'  already  alluded  to, 
is  an  admirable  application  for  all  wounds.  It  is  soft  and  compressible, 
and  very  absorbent,  and  possesses  the  great  quality  of  not  sticking  to  the 
wound." 

Jonathan  Hutchinson,  Jr.,  of  the  London  Hospital,  says:  "An  ideal 
dressing  for  wounds  in  which  some  oozing  is  certain  to  occur — e.  g., 
excisions  of  joints — is  afforded  by  a  moist  sterilized  gauze  bandage. 
This  is  dipped  in  weak  carbolic  solution,  and  applied  directly  over  the 
wound,  and  made  to  cover  the  limb  above  and  below  for  some  distance. 
As  the  bandage  dries  it  contracts,  and  therefore  it  must  not  be  employed 
too  tightly.  Absorbent  wool  is  applied  outside  this  bandage,  and  secured 
with  a  second  one. 

"The  wounded  part  should  be  kept  in  the  open  air— i.  e.,  should  be  as 
far  as  possible  uncovered  by  the  bedclothes.  This  will  be  more  or  less 
inevitable  with  wounds  of  the  head,  neck,  and  upper  extremity.  The 
lower  limb,  after  operation,  should  be  quite  uncovered  by  the  bed- 
clothes. The  atmosphere  under  bedclothes  is  limited,  is  hot,  is  moist, 
and  is  frequently  foul,  as  after  the  use  of  the  bedpan.  The  exposed 
limb  may  be  wrapped  up  during  the  cold  weather,  and  in  my  wards, 
where  no  wound  of  the  extremities  was  ever  allowed  to  be  covered  by 
bedclothes,  I  never  heard  any  complaint  on  the  ground  of  the  part  being 
unduly  cold. 

"In  operations  about  the  pelvis,  such  as  castration  and  the  radical 
cure  of  varicocele,  the  part  can  be  kept  in  a  reasonably  healthy  atmos- 
phere by  a  simple  arrangement  of  the  clothes  over  a  bed-cradle." 

In  minor  or  surface  sepsis  following  operations  Pryor  recommends 
the  following  method  of  treatment  (Pryor's  "Gynecology,"  page  293): 
"If  the  sepsis  has  resulted  from  a  plastic  operation  the  wound  should  be 
carefully  examined,  and  if  evidences  of  infection  are  present  the  sutures 
in  the  center  of  the  involved  area  should  be  at  once  removed  and  the 
edges  of  the  wound  separated  sufl&ciently  to  allow  of  irrigation  of  the 
wound.  It  may  be  the  infection  will  be  about  one  suture  only,  but 
sufficient  sutures  must  be  removed  to  enable  the  operator  to  wash  out 
the  wound  and  apply  his  dressings,  even  if  all  must  be  removed.     A 


lOO  POSTOPEEATIVE    TREATMENT. 

dressing  whicn  was  devised  by  the  late  Professor  Van  Arsdale  has  no 
equal.  For  instance,  assuming  the  infection  to  be  in  the  surface  of  a 
laparotomy, — and  most  of  them  are  between  the  skin  and  fascia, — 
enough  sutures  are  removed  to  expose  the  involved  parts,  and  after  all 
pus  is  washed  out  and  the  edges  of  the  wound  irrigated  with  normal  salt 
solution,  the  wound  is  thoroughly  dried.  Into  such  a  cavity  gauze 
soaked  in  a  mixture  of  balsam  of  Peru  i  part  and  castor  oil  8  parts  is 
introduced,  and  the  whole  covered  with  rubber  tissue.  This  dressing 
must  be  renewed  every  day.  Bacteriologic  examinations  of  many 
thousands  of  cases  have  shown  that  even  the  most  virulent  types  of 
streptococcic  infection  have  been  controlled  by  this  simple  method  of 
treatment.  If  the  infection  is  in  the  cervix  after  amputation,  all  sutures 
should  be  ripped  out  and  the  surface  painted  with  pure  carbolic  acid  and 
the  vagina  packed  with  strong  iodoform  gauze.  If  after  perineorrhaphy 
the  wound  becomes  infected  sufficient  stitches  must  be  removed  to 
allow  of  irrigation."  In  short,  surface  infections  are  to  be  treated  by 
evacuation  and  drainage  and  the  application  of  such  sterilized  prepara- 
tions as  have  been  found  appropriate  to  the  location  in  which  the  in- 
fection has  taken  place. 

Principles  Which  Govern  the  Treatment  of  Infected  Wounds. — 
This  subject  is  well  epitomized  by  J.  Chalmers  DaCosta,  Jr.,  who  in  a 
clinical  lecture  says: 

"A  wound  made  by  the  surgeon  after  the  parts  have  been  care- 
fully prepared  for  operation  is  a  clean  wound,  and  irritating  antiseptics 
should  never  be  introduced  into  it.  The  wound  edges  are  carefully  ap- 
proximated, drainage  being  introduced  only  if  the  wound  is  extensive; 
if  there  exist  in  it  dead  spaces  that  cannot  be  satisfactorily  obliterated  by 
pressure ;  if  the  patient  is  very  fat ;  or  if  the  skin  is  so  tender  that  it  is 
obviously  incapable  of  withstanding  moderate  pressure.  The  wound  is 
dressed  with  dry,  aseptic  dressings.  These  points  have  previously  been 
dwelt  upon. 

"Every  wound  inflicted  by  an  accident  is  regarded  as  contaminated 
from  the  very  beginning.  Such  a  wound  undoubtedly  contains  numbers  of 
bacteria.  If  it  is  not  properly  treated,  there  will  be  subsequent  suppura- 
tion of  the  tissues  or  putridity  of  the  blood-clot  and  of  the  discharges; 
and  it  may  even  be  that  there  will  develop  some  grave  condition,  such  as 
tetanus,  erysipelas,  septicemia,  or  pyemia.  It  is  the  surgeon's  duty  to 
cleanse  with  the  utmost  care  an  accidental  wound. 

"In  treating  such  a   wound,  we  follow  the  formula  already  laid 


TREATMENT   OF  ASEPTIC  AND    SEPTIC   WOUNDS.  lOI 

down.  In  the  first  place,  if  the  hemorrhage  is  dangerous,  it  is  tempo- 
rarily arrested ;  in  the  second,  if  there  is  serious  shock,  we  adopt  the 
proper  measures  to  obtain  reaction;  in  the  third,  we  remove  foreign 
bodies  and  cleanse  the  wound;  in  the  fourth,  we  permanently  arrest 
hemorrhage;  and,  finally,  we  provide  for  drainage,  consider  the  question 
of  approximating  the  edges,  and  apply  the  dressings. 

"The  methods  of  cleansing  such  a  wound  depend  somewhat  upon 
the  nature  and  the  situation  of  the  injury.  In  an  ordinary,  clean-cut, 
incised  wound,  inflicted,  let  us  say,  with  a  razor  or  a  penknife, — an 
instrument,  that  is,  of  course,  dirty,  but  is  not  likely  to  be  covered  with 
malignant  bacteria, — we  should  scrub  the  skin  about  the  wound  with 
soap  and  water,  wash  it  with  alcohol,  and  scrub  it  with  corrosive  subli- 
mate solution,  the  solution  being  hot  and  of  a  strength  of  i  :  looo. 
The  wound  itself  should  be  irrigated  with  a  hot  solution  of  corrosive 
sublimate  of  the  same  strength.  It  should  then  be  irrigated  with  a 
normal  salt  solution,  to  remove  the  excess  of  corrosive  sublimate. 

"In  any  region  but  the  face,  drainage  should  be  provided  for,  either 
by  pieces  of  iodoform  gauze  or  by  a  drainage-tube.  Such  a  wound 
about  the  face  may  with  safety  be  completely  sutured,  because  the 
blood-supply  is  so  excellent.  In  a  wound  of  the  scalp,  however,  capil- 
lary drainage  should  always  be  provided  for  by  the  insertion  of  silkworm- 
gut.  It  is  necessary  to  drain  these  wounds,  unless  they  are  on  the  face, 
even  thoiigh  the  infection  has  not  been  gross;  because  the  necessary 
introduction  of  an  irritant  antiseptic  causes  a  certain  amount  of  tissue 
necrosis,  and  increases  considerably  the  flow  of  wound-fluid.  If  egress 
for  this  fluid  is  not  obtained,  the  wound  will  become  unhealthy  and  will 
not  undergo  aseptic  repair. 

"In  dealing  with  a  lacerated  wound  the  surgeon  carefully  examines 
all  the  damaged  tissue,  and  the  tissue  that  he  regards  as  hope- 
lessly damaged  should  be  cut  away  with  scissors;  for  if  such  tissue  is 
allowed  to  remain,  it  becomes  necrotic  and  makes  infection  ine^'itable. 
A  lacerated  wound  should  be  irrigated  with  corrosive  sublimate  and 
washed  with  salt  solution,  and  should  then  have  dusted  into  it  iodoform, 
which  may  serve  to  retard  the  putrefaction  in  necrotic  masses  which, 
to  a  greater  or  less  extent,  are  certain  to  form.  It  is  never  closely  approx- 
imated with  sutures.  In  many  instances  no  sutures  are  used,  the  wound 
being  left  wide  open;  in  other  cases  a  few  sutures  are  inserted.  Such 
a  wound  should  be  drained  by  inserting  a  piece  of  iodoform  gauze. 

"A  punctured  wound  is  very  dangerous,  even  when  there  are  but  few 


I02  POSTOPERATIVE    TREATMENT. 

bacteria.  It  cannot  be  cleansed  unless  enlarged  by  an  incision.  The 
rule  of  treatment  in  these  cases  is  to  sterilize  the  skin;  to  make  a  free 
incision  to  the  very  depths  of  the  puncture  ;  to  moisten  the  skin-edges 
with  alcohol ;  and  to  swab  out  the  wound  with  pure  carbolic  acid.  Half 
a  minute  after  the  acid  has  been  introduced  the  wound  should  be  swabbed 
with  alcohol.  The  great  germicidal  value  of  carbolic  acid  has  long 
been  known,  and  the  antidotal  effect  of  alcohol  has  been  demonstrated 
by  Seneca  Powell,  of  New  York  city.  Such  a  wound  must,  of  course, 
be  drained;  and  this  is  usually  accomplished  by  inserting  a  strand  of 
iodoform  gauze. 

"The  details  of  the  management  of  other  forms  of  wounds  and  of 
wounds  in  particular  regions  will  be  discussed  under  the  proper  head- 
ings. It  is  necessary,  however,  to  refer  here  to  wounds  that  are  grossly 
infected  by  the  introduction  of,  for  example,  street  dirt.  Ordinary 
methods  of  cleansing  will  in  such  a  case  prove  perfectly  futile,  and  the 
following  plan  should  be  pursued :  Sterilized  olive  oil  is  poured  into 
the  wound,  after  which  the  wound  itself,  as  well  as  the  skin  around  it, 
is  scrubbed  with  soap  and  water.  The  oil  entangles  the  masses  of  dirt, 
and  the  soap  and  water  removes  the  oil  with  the  dirt.  After  this  has 
been  done,  the  wound  may  be  irrigated  with  corrosive  sublimate,  and 
then  with  normal  salt  solution;  or,  what  is  better,  it  should  be 
first  swabbed  with  pure  carbolic  acid  and  then  washed  with  alcohol. 
The  skin  about  the  wound  is  cleansed  in  the  usual  manner. 

"A  primarily  infected  area  should  be  dressed  with  hot  antiseptic 
fomentations.  The  use  of  heat  in  such  an  area  is  of  the  first  impor- 
tance :  it  lessens  pain,  diminishes  stasis,  increases  the  activity  of  the  leuko- 
cytes, favors  migration,  and  brings  hordes  of  leukocytes  to  the  part ;  and 
the  leukocytes  not  only  carry  away  dead  material,  but  actively  attack 
bacteria  and  surround  the  area  of  infection  with  an  encompassing  pro- 
tective barrier.  We  therefore  employ  hot,  moist  dressings  until  the 
wound-discharge  is  seen  to  be  thin  and  scanty;  and  until  we  are  sure 
that  constitutional  symptoms  will  not  develop,  or  until  developed  con- 
stitutional symptoms  have  passed  away.  Then,  the  wound  having 
become  an  area  of  granulation-tissue,  we  can  substitute  dry  aseptic  dress- 
ings. 

"Rest  is  of  the  very  greatest  importance — rest  in  bed  for  a  severe 
wound,  and  rest  upon  splints  for  a  wound  of  the  extremities.  Rest  in 
bed  lessens  the  force  and  the  frequency  of  the  heart-beats,  diminishes 
the  amount  of  blood  sent  to  the  inflamed  area,  and  conserves  the  pa- 


TREATMENT    OF    ASEPTIC    AND    SEPTIC    WOUNDS.  IO3 

tient's  strength,  consequently  increasing  his  vital  resistance.  The  use 
of  rest,  either  in  bed  or  upon  splints,  by  lessening  or  preventing  muscular 
motion,  diminishes  the  danger  of  the  breaking-down  of  the  protective 
barrier  of  leukocytes  that  lies  between  the  wound  and  the  system  at 
larger 

"If  in  spite  of  all  this  care  a  serious  infection  ensues,  and  the  wound 
becomes  unhealthy  or  the  patient  develops  constitutional  symptoms, 
we  must  apply  such  methods  of  treatment  as  I  have  previously  discussed. 
The  surgeon  may  be  called  to  see  a  patient  that  has  received  a  wound 
a  number  of  days  before  and  whose  wound  is  already  diseased.  When 
a  wound  of  this  sort  begins  to  show  evidences  of  infection,  the  surgeon 
should  promptly  interfere.  The  evidences  of  infection  are  pain,  which 
becomes  pulsatile ;  discoloration,  which  becomes  dusky ;  swelling,  which 
at  an  early  date  will  be  accompanied  with  edema  of  the  skin ;  and  con- 
stitutional evidences  of  surgical  or  suppurative  fever. 

"If  such  a  wound  has  been  closed  with  sutures,  some  or  all  of  them 
should  immediately  be  cut,  so  as  to  afford  drainage.  The  wound  must 
be  gently  irrigated  with  warm  normal  salt  solution.  Irritant  antiseptics 
are  not  used.  They  are  of  value  in  preventing  infection,  but  of  Uttle 
use  when  infection  has  occurred,  and  they  may  do  harm  by  destroying 
the  barrier  of  leukocytes.  Drainage  is  to  be  secured  by  introducing 
a  drainage-tube  or  strands  of  iodoform  gauze.  If  the  wound  is  putrid, 
iodoform  should  certainly  be  used.  The  part  must  be  placed  at  rest 
and  dressed  with  antiseptic  fomentations." 


CHAPTER  VI. 

ADJUNCTS  OR  AIDS   IN   POSTOPERATIVE 
TREATMENT. 


CHAPTER  VI. 

ADJUNCTS  OR  AIDS  IN  POSTOPERATIVE  TREATMENT. 

Hypodermatoclysis. — Hypodermatoclysis  is  the  introduction  of 
saline  fluid  into  the  subcutaneous  cellular  tissue.  The  fluid  may  be  intro- 
duced by  means  of  a  fountain  syringe  and  an  aspirating  trocar  and  cannula, 
but  best  by  a  fountain  syringe  and  a  properly  fitting  hollow  needle.  After 
the  skin  has  been  sterilized,  the  trocar  or  needle  is  plunged  into  the  sub- 
cutaneous tissue  of  the  loin,  buttock,  subscapular  region,  or  submam- 
mary region.  The  best  region  to  use  for  this  injection  is  perhaps  the 
iliolumbar,  the  space  between  the  crest  of  the  flium  and  the  twelfth  rib. 
It  is  practically  the  point  of  least  motion  in  the  body,  and  does  not  inter- 
fere with  the  dorsal  position  or  cause  pain  through  movements  of  the 
limbs  or  from  abdominal  or  thoracic  respiration.  The  trocar,  if  this  is 
used,  is  withdrawn,  the  cannula  being  left  in  place.  A  fountain  syringe 
previously  filled  with  hot  sterile  salt  solution  is  used.  The  ordinary  formula 
used  is  a  0.6  percent  salt  solution  in  boiled  and  filtered  water.  One  dram 
of  the  solution  to  one  pound  of  body- weight  is  the  maximum  quantity  that 
should  be  used  at  one  time,  administered  at  a  temperature  of  108°  to 
110°  F.  Some  surgeons  prefer  the  addition  of  25  percent  sodium  car- 
bonate to  75  percent  salt  solution,  as  recommended  by  Tavel,  especially 
for  the  irrigation  of  fresh  or  infected  wounds.  Others  prefer  plain  sodi- 
um chlorid,  the  proportion  of  which  should  be  not  less  than  6  percent  or 
more  than  9  percent.  It  is  still  an  unsettled  question  which  is  the  best. 
A  larger  percentage  of  salt  is  irritating,  and  increases  the  danger  of 
necrosis.  The  stock  solution  used  in  Halsted's  clinic  is  as  follows: 
Sodium  chlorid  0.9  part,  potassium  chlorid  0.03  part,  calcium  chlorid 
o.oi  part,  distilled  water  99.06  parts;  50  c.c.  of  the  stock  solution  is 
added  to  950  c.c.  of  distilled  water.  After  sterilization  it  is  ready  for 
use.  The  formula  introduced  by  F.  S.  Locke  has  proved  most  efiicacious 
in  our  hands.  It  is  as  follows:  Calcium  chlorid  0.25  gram,  potassium 
chlorid  o.i  gram,  sodium  chlorid  0.9  gram,  water  i  liter.  The  tube  of  the 
syringe  is  attached  to  the  trocar,  and  the  reservoir  is  hung  several  feet 
above  the  level  of  the  bed.     The  fluid  should  run  in  very  slowly,  and 

107 


I05  POSTOPERATIVE    TREATMENT. 

absorption  will  be  greatly  facilitated  by  occasionally  massaging  the  infil- 
trated area.  After  about  a  pint  has  been  introduced,  the  cannula  is 
removed,  and  the  small  puncture  in  the  skin  is  closed  with  collodion. 
If  the  condition  of  the  patient  is  such  that  more  than  a  pint  must  be 
given,  the  operation  is  repeated  in  another  region. 


Fig.  7. — Howard  A.  Kelly's  Saline  Infusion  Apparatus,  Consisting  of  a 
Graduated  Glass  Reservoir  Fitted  with  Stopper  and  Force  Bulb, 
WITH  Rubber  Tubing,  Pinch-cock,  and  Needle  Attached. 

The  rapidity  of  absorption  depends  considerably  upon  the  condition 
of  the  circulation,  and  with  a  rapid  or  feeble  heart  with  poor  action  of 
the  capillaries,  it  is  a  much  slower  method  than  enteroclysis.  The  dan- 
ger of  overdistention  here  becomes  important.  If,  however,  in  such  a 
case  with  the  hypodermoclysis  we  combine  enteroclysis  with  normal  salt 
solution  at  a  temperature  of  120°  F.,  the  heart  is  immediately  started  up 
and  absorption  of  the  subcutaneous  fluid  occurs  more  rapidly.  For 
practical  purposes  the  fluid  may  be  injected  once,  twice,  or  three  times 
during  twenty-four  hours,  depending  upon  the  reaction  and  the  rapidity 
of  absorption.  In  an  adult  six  ounces  to  a  pint  is  indicated  in  uremia 
and  allied  conditions ;  from  a  pint  to  a  quart,  if  there  is  shock  or  hemor- 
rhage. Gentle  peripheral  massage  assists  absorption.  As  there  is  con- 
siderable loss  of  heat  in  passing  through  the  tube,  the  fluid  should  be  at 
a  temperature  of  from  1 15°  to  120°  F.  Indications  for  stopping  the  flow 
may  be  deduced  from  the  effects  produced  by  the  procedure.     Subcu- 


ADJUNCTS    OR    AIDS    IN    POSTOPKRATIVK    TRKATMICNT.  IO9 

taneous  injections  increase  the  (|uantity  of  lluid  in  the  vessels  by  replac- 
ing that  which  has  been  lost  by  hemorrhage.  It  adds  to  the  circulation, 
and,  therefore,  stimulates  a  rapid  and  feeble  heart,  as  in  shock ;  it  dilutes 
the  poison  and  aids  in  eliminating  toxic  products  through  its  diuretic 
action,  as  in  sepsis  or  uremia;  it  is  asserted  by  many  to  have  a  hemo- 
static effect,  and  hence  is  of  benefit  in  various  kinds  of  hemorrhage. 
Hypodermoclysis  is  an  operation  that  should  be  performed  with  care  and 
close  attention  to  detail.  All  dangers  of  infection  may  be  avoided  by 
proper  sterilization  of  the  apparatus  used,  the  solution,  and  the  skin  of 
the  patient. 

Intravenous  Injection.- — Intravenous  injection  of  saline  fluid  is 
especially  indicated  in  shock,  hemorrhage,  sepsis,  and  suppression  of 
urine.  One  of  the  most  modern  and  best  instruments  for  this  purpose 
is  the  Spencer- Collins  portable  apparatus,  consisting  of  a  nickel-plated, 
flat  reservoir,  five  and  one-half  inches  high  by  four  inches  long, 
and  one  and  five-eighth  inches  wide,  to  the  bottom  of  which  is  attached 
a  force  pump  with  glass  barrel  surmounted  with  a  metal  cylinder,  also 
trocar  and  cannula  of  metal.  The  pump  is  detachable,  thus  permitting 
the  various  parts  to  be  carried  inside  the  reservoir,  making  a  neat,  com- 
pact apparatus,  all  parts  of  which  can  be  sterilized.  When  the  reservoir 
is  filled  and  the  piston  of  the  syringe  is  pulled  out,  one-half  ounce  of  the 
fluid  passes  into  the  barrel  of  the  syringe,  and  when  the  piston  is  pushed 
in,  this  amount  of  fluid  is  projected  through  the  cannula  into  the  vein. 
A  simple  glass  funnel,  tube,  trocar,  and  cannula  make  a  very  satisfactory 
apparatus  and  are  preferred  by  many  to  the  more  elaborate  outfit.  After 
thorough  sterilization  of  the  skin,  the  forearm  is  partially  supinated,  and 
an  incision  one  to  two  inches  long  is  made  over  the  median  basilic  vein, 
through  the  skin  and  superficial  fascia.  With  a  blunt  instrument  the 
adipose  tissue  is  torn  through  and  the  vein  exposed,  and  lifted  from  its 
bed;  two  catgut  ligatures  are  carried  under  the  vein  and  one  is  drawn 
toward  the  distal  extremity  of  the  wound  and  tied  securely,  thus  ligating 
the  vein  in  continuity.  The  other  ligature  is  drawn  toward  the  proximal 
extremity  of  the  wound,  and  one  knot  is  loosely  tied;  with  a  dehcate 
pair  of  thumb  forceps  grasp  the  periphery  of  the  vein  and  with  a  sharp 
pair  of  curved  scissors  cut  half-way  through  the  diameter  of  the  vein 
transversely,  immediately  under  the  bite  of  the  forceps.  This  makes  a 
free  opening  into  the  vein,  guarded  by  a  flap  in  the  grasp  of  the  forceps. 
The  blood  now  runs  out  freely,  and  would  obscure  the  opening  but  for 
the  grasp  of  the  forceps.     Lifting  the  little  flap  with  the  forceps  in  one 


no 


POSTOPERATIVE    TREATMENT. 


hand,  the  cannula,  with  the  fluid  running  to  prevent  any  air  entering  the 
vein,  is  thrust  quickly  into  the  opening;  the  ligature  which  was  only 
lightly  tied  is  now  tied  down  on  the  vein  and  cannula,  which  thus  pre- 
vents leakage  of  the  fluid  from  the  vein.  When  the  cannula  is  with- 
drawn, this  ligature  is  simply  tied  firmly  down,  closing  the  vein  perma- 
nently.    That  part  of  the  vein  between  the  two  ligatures  may  be  excised 


Fig.  S. — Hypodermatoclysis. 

or  let  alone.     The  skin  incision  is  closed  with  sutures  and  an  aseptic 
dressing  applied  to  the  part. 

The  quantity  of  saline  fluid  to  be  injected  varies  according  to  age, 
the  amount  of  fluid  lost  in  cases  of  hemorrhage,  and  the  reaction  signs 
in  cases  of  shock  or  collapse.     In  cases  in  which  there  has  been  marked 


ADJUNCTS   OR   AIDS   IN   POSTOPERATIVE   TREATMENT.  Ill 

hemorrhage,  the  amount  should  be  greater  than  in  simple  collapse  or 
shock.  The  quantity  ranges  from  a  few  ounces  to  two  or  three  quarts. 
The  chief  guide  in  all  cases  is  the  return  of  the  pulse,  with  increase 
in  volume  and  diminution  in  rate,  and  the  return  of  color,  facial  ex- 
pression, and  consciousness. 

Locke's  solution  with  or  without  adrenalin  is  preferable.  The 
temperature  of  the  solution  should  be  kept  at  i  io°  F.  The  fluid  should 
flow  in  very  gently,  and  a  second  injection  is  rarely  necessary,  although 
in  cases  of  prolonged  shock  or  sepsis  the  injections  may  be  repeated 
every  four  to  six  hours. 

Rectal  Alimentation.-^After  many  operations  rectal  feeding  is 
of  such  importance  that  the  attending  surgeon  should  be  thoroughly 
conversant  with  the  subject.  There  is  a  wide  difference  of  opinion  as 
to  what  constitutes  the  best  preparation  or  most  easily  assimilated 
foods  for  this  purpose.  So  many  formulas  have  been  advanced  that 
are  absolutely  inert,  if  not  harmful,  that  I  have  deemed  it  best  to  give 
in  detail  what  we  have  found  from  actual  experience  to  be  the  most 
valuable  and  useful.  There  are  certain  foods  which  the  rectum  as- 
similates, and  others  which  it  rejects.  Starches,  oils,  and  fats  should 
not  be  given,  for  the  bowel  is  intolerant  of  them,  and  oils  and  fats, 
by  coating  the  mucous  membrane,  prevent  the  absorption  of  nutrient 
material  much  in  the  same  way  that  mucus  does. 

J.  N.  Jerome  ("Int.  Med.  Jour."),  in  an  article  upon  this  subject, 
emphasizes  certain  points  as  essential: 

"i.  The  quantity  and  quahty  of  food  should  be  so  regulated  as 
to  avoid  exciting  peristalsis,  and  also  that  the  first  injection  should 
be  entirely  absorbed  before  another  is  given. 

"2.  The  irritation,  if  any,  of  the  bowel  should  be  allayed.  Some- 
times in  extreme  irritability  opium  may  have  to  be  used,  but  it 
is  well  to  avoid  it,  if  possible.  While  opium  checks  peristalsis  and 
favors  the  retention  of  the  enema,  yet  it  also,  to  a  certain  extent,  in- 
hibits the  absorption  of  the  nutrient  material. 

"3.  The  rectum  should  be  cleansed  of  all  mucus,  feces,  and  foreign 
matter." 

The  author  insists  upon  great  care  as  to  detail,  since  carelessness 
may  produce  rectal  irritation  and  intolerance  of  food.  When  properly 
given,  although  the  enemas  may  not  be  retained  the  first  day  or  two, 
the  proper  nutrition  can  soon  be  administered  in  this  manner.  It  can 
seldom,  however,  be  given  a  long  time  without  producing  diarrheas, 


112  POSTOPERATIVE    TREATMENT. 

and  in  these  cases  it  is  well  to  withhold  the  enemas  until  the  irritation 
has  subsided. 

"Hemorrhoids  are  a  severe  stumbling-block  in  successfully  using 
this  method,  but  their  presence  is  not  a  positive  contraindication.  In 
these  cases  only  the  softest  rubber  catheter  should  be  used  and  local 
anesthesia  of  piles  established  by  the  topical  application  of  a  2  percent 
solution  of  cocain. 

"When  the  enemas  are  long  continued  it  is  well  to  wash  out  the 
rectum  at  least  once  a  day  with  warm  water,  soapsuds,  or  boric  acid 
solution.  By  this  means  all  foreign  matter  is  removed,  feces  are  dis- 
lodged, and  mucus  and  any  remains  of  a  former  injection  washed 
away.  It  is  very  important  to  use  only  those  articles  of  food  which 
are  completely  absorbed.  All  other  material  acts  as  a  foreign  body 
and  causes  irritation  of  the  rectum." 

The  best  forms  of  food  to  employ  are  among  the  following: 

"Milk. — This  is  universally  used.  It  should  not  be  too  rich, 
for  the  fat  in  the  cream  is  not  absorbed,  and  prevents  the  absorption 
of  the  milk  proper.  It  is  well,  sometimes,  to  use  predigested  milk, 
and  thus  save  the  rectum  a  certain  amount  of  labor. 

"Eggs. — The  white  of  egg  is  one  of  the  best  ingredients  of  enemas. 
The  yolk  should  not  be  used,  for  it  is  too  rich  in  fats.  It  is  preferable 
that  the  eggs  be  partially  predigested  by  the  addition  of  a  peptogenic 
or  pancreatinizing  powder.  This  may  be  added  to  the  peptonized 
milk  or  to  a  peptone  solution  of  meat  extract.  A  little  salt  may  be 
added  to  the  eggs  to  promote  absorption,  but  it  is  sometimes  irritating 
to  the  rectum. 

"Alcohol. — Used  for  rectal  injections  should  be  of  the  best  and 
purest  kind.  Rum,  brandy,  or  sherry  wine  may  be  used,  but  a  good 
whisky  is  by  far  preferable.  It  can  be  used  in  connection  with  the 
other  rectal  foods,  but  if  too  strong  may  precipitate  the  curds  in  the 
milk. 

"Meat  Extract. — A  peptone  Solution  of  meat  extract  may  also 
be  used  alone  or  in  combination  with  any  of  the  foods  above  enu- 
merated. 

"  Defibrinated  Beef-blood. — This  also  is  used  to  some  extent. 
The  beef-blood  is  prepared  by  whipping  with  light  switches.  The 
only  objection  to  this  is  the  odor  which  it  leaves. 

"All  injections  should  be  given  at  a  temperature  of  from  90°  to 
95°  F.     If  colder  or  warmer,  they  may  excite  peristalsis  and  cause 


ADJUNCTS   OR  AIDS   IN   POSTOPERATIVE   TREATMENT.  II 3 

rejection  of  food.  The  number  of  injections  depends  to  a  great  extent 
upon  the  condition  of  the  rectal  walls.  It  is  usually  advisable  to  give 
one  every  six  hours,  and  then,  if  retained  and  absorbed,  they  can  be 
increased  to  one  every  four  or  three  hours. 

In  giving  an  enema,  it  is  well  to  use  only  a  soft-rubber  catheter  or 
tube.  In  the  selection  of  the  tube,  one  should  be  chosen  that  is  not 
so  stiff  as  to  cause  injury  to  walls  nor  so  soft  as  to  double  upon  itself 
if  a  little  force  is  used.  It  should  be  lubricated  with  sweet  oil,  vaselin, 
butter,  or  glycerin. 

"The  enema  may  be  given  by  means  of  a  small  hard- rubber  syringe, 
or,  as  I  prefer,  a  fountain  syringe.  There  should  be  but  little  force 
exerted  and  the  patient  instructed  not  to  strain.  The  tube  should  be 
introduced  from  eight  to  twelve  inches  into  the  bowel.  Care  should  be 
taken  that  no  air  enters  the  bowel,  as  it  excites  peristalsis,  and  this  is  pre- 
vented by  filling  the  tube  with  enema  just  before  it  is  introduced." 

There  are  many  special  preparations  on  the  market  especially  recom- 
mended for  this  purpose,  but  these  are  not  so  uniformly  successful. 
Among  those  which  are  often  employed  are  peptonoids,  panopeptone, 
somatose,  and  liquo-peptone,  various  beef-juices,  and  other  similar 
preparations. 

The  following  formulas  are  used  in  the  Philadelphia  Hospital : 

1.  Beef-tea, 3  ounces.       3.  Beef  essence,   6  ounces. 

Yolk  of  one  egg,  Whites  of  two  raw  eggs, 

Brandy, ^  ounce.  Peptonized  milk, 2  ounces. 

Liquor  pancreaticus, 2  drams.  Two  eggs. 

2.  Beef-tea, 2  ounces.       4.  Whites  of  three  eggs, 

Brandy, §  ounce.  Ox  serum, 4  ounces. 

Cream, J      "                  Starch,  raw, i  ounce- 
Salt,  I  dram. 

Normal  Salt  Solution. — Many  modern  surgeons  rely  solely  upon 
normal  salt  solution.  Ochsner  prefers  one  ounce  of  liquid  peptonoids 
and  three  ounces  of  normal  salt  solution  given  every  three  to  four  hours 
by  attaching  an  ordinary  glass  syringe  (piston  removed)  to  a  No.  8  or  lo 
soft-rubber  catheter.  Insert  the  catheter  two  or  three  inches  and  pour 
the  food  into  the  glass  syringe,  which  takes  the  place  of  a  funnel,  and  let 
it  enter  the  rectum  by  its  own  weight. 

We  have  followed  this  plan  in  several  instances  with  the  greatest  satis- 
faction. To  give  nutrient  injections  successfully,  the  solution  to  be  used 
must  be  at  a  temperature  of  ioo°  F.  It  should  be  introduced  very  slowly 
and  carried  very  gently  as  far  into  the  bowel  as  possible.  In  many  in- 
9 


114  POSTOPERATIVE    TREATMENT. 

stances  a  high  enema  tube  is  preferred  to  the  catheter.  The  quantity 
ordinarily  employed  should  not  exceed  four  ounces.  To  lubricate  these 
tubes  sterile  oliVe  oil  only  should  be  used. 

To  facilitate  retention  a  small  folded  napkin  is  wet  with  cold  water, 
and  placed  directly  against  the  anus  and  held  for  a  few  minutes;  this 
will  usually  overcome  any  tendency  toward  tenesmus.  The  bowels 
should  be  cleansed  at  least  once  each  day  by  copious  but  gentle  enemas 
of  normal  salt  solution. 

Subcutaneous  Feeding. — When  forced  feeding  is  necessary,  and 
when  no  nourishment  can  be  taken  by  the  stomach,  and  especially  when 
there  is  rapid  emaciation  from  want  of  nourishment,  and  frequently  if 
the  rectum  has  become  so  irritable  that  enemas  cannot  be  retained,  one 
to  two  ounces  of  sterilized  olive  oil  may  be  injected  into  the  subcutaneous 
tissue  of  the  groin.  The  oil  must  be  introduced  very  slowly,  and  should 
not  be  repeated  more  than  once  in  twenty-four  hours.  A  lo  percent  solu- 
tion of  grape-sugar  has  been  highly  extolled  by  English  surgeons  for  this- 
purpose,  but  seems  to  cause  considerable  irritation  at  the  site  of  injection. 

Inunctions.^ — A  certain  amount  of  nutritious  matter  can  be  intro- 
duced into  the  body  by  inunctions.  The  skin  must  be  prepared  by 
means  of  sponging  with  soap  and  water  and  by  frequent  light  massage. 
The  materials  usually  employed  are  sterile  olive  oil,  or  cod-liver  oil  two 
parts  and  alcohol  one  part.  George  Boody  has  used  with  success  leaf-lard 
inunctions  applied  thoroughly  twice  daily  to  the  chest,  abdomen,  and 
back.    The  patient 's  strength  is  undoubtedly  increased  by  such  treatment. 

Bandaging. — "The  object  of  bandages  is  not  only  to  hold  in  place 
surgical  dressings  and  splints,  but  they  are  frequently  employed  to  exert 
pressure  on  certain  parts,  control  hemorrhage,  relieve  congestion,  pro- 
mote absorption  of  extravasated  liquids  or  exudates,  to  prevent  edema, 
support  circulation,  weaken  vessels,  correct  deformities,  as  well  as  to 
^ive  protection  and  support  to  injured  limbs  and  joints."  (Brewer.) 

Bandages  are  made  of  gauze,  flannel,  cotton,  linen,  india-rubber,  and 
unbleached  muslin.  They  vary  in  width  and  length.  According  to 
Wharton  and  Curtis,  bandages  for  the  hands,  fingers,  and  toes  should 
be  one  inch  wide  and  three  yards  long;  for  the  extremities  in  children, 
two  inches  wide  and  six  yards  long;  for  the  extremities  in  adults,  two 
:and  a  half  inches  wide  and  seven  yards  long;  head-bandages,  two  inches 
wide  and  six  yards  long ;  thigh  and  groin  bandages,  three  inches  wide  and 
nine  yards  long;  trunk  bandages,  four  inches  wide  and  ten  yards  long. 
Tor  ordinary  purposes  the  best  material  for  bandages  is  unbleached 


ADJUNCTS    OR    AIDS    IN    POSTOPKRATI VK    TRKATMF.NT.  II5 

muslin,  which  is  first  washed  in  sodium  carbonate  solution  to  remov'c 
the  sizing,  and  is  then  torn  in  strips  of  the  desired  width  and  length. 
The  selvage  is  removed  and  the  stri{)  is  made  into  a  roll. 

In  postoperative  work,  when  employed  for  the  purjjose  of  retaining 
dressings,  the  application  of  the  bandage  may  be  begun  at  any  part  of 
the  limb  below  the  wound,  and  the  bandage  is  then  carried  to  the  point 
where  the  dressings  are  to  be  covered.  After  such  a  bandage  has  been 
applied,  if  the  patient  complains  of  too  much  constriction,  the  first  turns 
should  be  cut  with  scissors.  If  a  bandage  is  to  be  used  to  make  pressure 
on  any  portion  of  a  limb,  its  application  should  be  begun  at  the  fingers 
or  toes,  and  the  bandage  should  be  carried  up  to  the  place  where  the 
pressure  is  needed.  "  Compression  should  not  be  made  in  the  middle 
of  a  limb  by  a  tightly  applied  bandage  without  having  first  included  the 
fingers  or  toes,  as  such  a  procedure  would  produce  pain,  swelling,  and 
edema,  and,  if  prolonged,  might  cause  gangrene."     (Hare.) 

Bandages  to  Give  Support  and  Make  Compression. — If  we  are 
dealing  with  a  condition  which  is  in  need  of  support  and  compression, 
such  as  a  slight  sprain,  a  swollen  joint,  varicose  veins  of  the  leg,  or  eczem- 
atous  ulcers  of  the  lower  extremities,  bandages  made  of  some  elastic 
material  should  be  used,  such  as  flannel  cut  on  the  bias,  elastic  webbing, 
or  india-rubber.  There  are  two  forms  of  india-rubber  bandage  which  have 
special  names:  one  which  is  very  thin,  and  made  of  rubber  similar  to 
that  employed  in  making  rubber  dam,  is  known  as  Martin's  bandage, 
and  another,  made  of  web-elastic  and  known  as  Randolph's  bandage. 
They  may  be  used  for  practically  the  same  purposes.  Martin 's  bandage 
is  used  in  the  palliative  treatment  of  varicose  veins  of  the  leg.  Its  appli- 
cation may  cure  an  ulcer  of  the  leg  caused  by  varicose  veins,  but  it  would 
best  be  used  as  a  prophylactic  measure  in  varicose  conditions,  or  worn 
to  prevent  a  recurrence  of  the  leg  ulcer  once  it  is  cured.  This  bandage 
when  applied  will  give  an  elastic  support  wdiich  will  have  a  tendency  to 
turn  a  flow  of  venous  blood  from  the  superficial  veins  into  the  deep  veins. 
In  this  condition  the  Martin  bandage  should  be  applied  while  the  leg  is 
slightly  elevated  and  before  the  patient  arises  in  the  morning;  it  should 
not  be  removed  until  he  has  retired  at  night,  and  'after  it  has  been  re- 
moved it  should  be  washed  with  soap  and  water,  dried,  and  hung  up 
until  morning. 

When  it  is  desired  to  make  pressure  or  support,  in  case  of  sprain, 
varicose  veins,  effusions,  etc.,  the  flannel  bandage  is  most  useful  when 
cut  bias  and  made  of  sufficient  length,  as  it  is  then  much  more  elastic 
than  when  cut  straidit. 


Il6  POSTOPERATIVE    TREATMENT. 

Methods  of  Applying  the  Roller  Bandage. — If  the  part  to  be 
bandaged  is  of  even  size  throughout,  as  the  upper  arm  or  trunk,  the  free 
end  of  the  bandage  is  laid  upon  the  part  and  held  in  place  by  the  left 
hand,  while  the  roller  is  carried  by  the  right  hand  around  the  part  to  be 
bandaged  in  such  a  way  that  the  second  turn  will  hold  the  first  firmly  in 
place.     Each   revolution   of  the  bandage   covers  at  least  one-half  of 


Fig.  9. — Spiral  Reversed  Bandage  Applied  to  Forearm. 


Fig.  10. — Spiral  Reversed  Bandage  Applied  to  Leg. 

the  last  turn.  When  the  upper  limit  of  the  bandage  is  reached,  the 
end  is  pinned  to  the  layer  beneath.  If  the  part  to  be  bandaged  is 
conical,  as  the  leg  or  forearm,  the  spiral  reversed  bandage  is  applied,  in 
which  each  turn  is  made  to  fit  snugly  to  the  limb  by  being  turned  upon 
itself,  as  seen  in  Figs.  9  and  10;  or  the  figure-of-eight  bandage  is  em- 
ployed, in  which  the  lower  loops  of  bandage  are  snugly  and  evenly 


ADJUNCTS    OR   AIDS    IN    POSTOPKRATIVE    TREATMENT, 


117 


adapted  to  the  limb,  and  as  the  banchigc  ascenrls  they  eventually  cover  the 
more  loosely  applied  upper  loops.  On  the  leg  this  is  by  far  the  better  band- 
age for  ambulatory  patients.  Properly  applied,  it  will  remain  in  position 
for  days;  the  spiral  reverse  is  prone  to  loosen  and  slip  down  (Fig.  11). 
In  applying  a  bandage  to  the  groin  or  shoulder,  the  s]jica  is  employed, 
beginning  on  the  limb  and  making  a  figure-of-eight  around  the  limb 
and  trunk,  as  seen  in  Fig.  12.  In  bandaging  the  groin,  however,  especi- 
ally in  ambulatory  patients, 
this  bandage  will  remain  in 
position  much  better  if  a  few 
turns  are  carried  directly 
around  the  waist  (Fig.  13). 

In  bandaging  the  thumb 
or  one  of  the  fingers,  the  free 
extremity  is  covered  with  the 
spiral  reversed;  and  when 
the  base  is  reached  the  spica 
is  used,  the  upper  loop  of 
which  encircles  the  digit  and 
the  lower  loop  the  hand  and 
wrist  (Fig.  14). 

In  bandaging  the  knee, 
the  figure-of-eight  is  used, 
the  first  turn  being  taken 
around  the  joint  opposite  the 
middle  of  the  patella,  after 
which  the  loops  alternate, 
one  being  applied  above  and 
the  next  below  the  first  turn 
(Fig.  15).  In  bandaging  the 
head,  one  or  two  loops  are 
made  to  encircle  the  head, 

passing  from  the  frontal  region  just  above  the  eyes  around  the  occi- 
pital protuberance;  the  bandage  is  then  applied  in  a  transverse  direc- 
tion, beginning  just  above  one  ear  and  carrying  the  first  turn  over  the 
center  of  the  vault  to  the  opposite  ear;  then  a  number  of  turns  are 
taken  between  these  two  points  alternately  in  front  of  and  behind  the 
first  until  the  entire  vault  is  covered.  The  loops  made  by  reversing 
the  bandage  just  above  each  ear  are  firmly  held  until  all  the  trans- 


FlG.    II.- 


FlGURE-OF-ElGHT   REVERSED    BaXDAGE 

Applied  to  Leg. 


IIJ 


POSTOPERATIVE    TREATMENT. 


verse  turns  are  made,  and  finally  secured  by  three  or  four  encircling  turns 
around  the  forehead  and  occiput,  safety-pins  being  finally  introduced 


Fig.   12. — Spica  Bandage  Applied  to  Left  Srouldee. 


Fig.   13. — Single  Spica  Bandage  Encircling  the  Waist.— (.4//er  Bassini.) 


to  hold  all  in  place  (Fig.  16).     The  folds  covering  the  vault  may  also 
be  made  longitudinally  if  desired  (Fig.  17). 


A]:)JCJNCTS    OR    AIDS    TN    POSTf )l>KRA'riVI';    'I'KKA'I'MKNT. 


719 


In  l:)an(]aging  an  ampulali()n-slum|),  make  one  or  two  circular  turns 
around   llic  circumference  of  the  stump,   then  a    numljcr  of  recurrent 


Fig.  14. — Spica  Bandage  Applied  to  Finger  with  Loop  of  Hand  and  \\'rist. 


Fig.   15. — Proper  Method  of  Applying  B.a,nd.a.ge  to  Knee. 


turns  at  a  right  angle  to  these,  inclosing  the  extremity,  and  holdmg  these 


I20 


POSTOPERATIVE    TREATMENT. 


in  place  by  a  circular  or  reversed  spiral  from  the  extremity  upward  until 
a  joint  or  some  bony  protuberance  is  covered  to  hold  it  in  place. 

The  ModieiedVelpeau  Bandage  for  Holding  the  Arm  Securely 
TO  THE  Chest- WALL. — Place  the 
hand  of  the  injured  side  on  the  op- 
posite shoulder;  take  two  or  three 
turns  of  a  wide  roller  bandage 
around  the    thorax,   including   the 


Fig.  i6. — Gibson's  Bandage. 
— (Wharton.) 


Fig.  17. 


-Modified  Barton's  Bandage. 
- — (Wharton.) 


arm;  then  pass  the  bandage  from  the  free  axilla  behind  to  the  fixed 
shoulder,  passing  over  this  shoulder  from  behind  forward;  carry  the 
bandage  around  the  point  of  the  elbow  and  then  upward  behind  the 

same  shoulder  over  its  summit  down- 
ward in  front  to  the  free  axilla,  then 
circularly  around  the  chest,  alternat- 
ing these  turns  until  the  entire  arm 
and  chest  are  included  (Fig.  18).  All 
these  methods  may  be  modified  to 
meet  special  indications. 

The  triangular  or  folded  hand- 
kerchief bandage  is  made  by  folding 
a  square  piece  of  muslin  or  gauze 
into  a  triangle.  This  can  be  applied 
over  a  bulky  dressing  of  the  hand  or 
amputation-stump    by    placing    the 

Fig.  18.— Spica  Bandage  Applied       base  of  the  triangle  at  a  right  angle 
FOR    Operations    on  Shoulder  ^  r  ^  t- 

OR  Clavicle.  to  the  limb  and  folding  the  apex  over 


ADJUNCTS    OR    AIDS    IN    POSTOPKRATIVl',    TRKATMENT. 


121 


its  extremity,  and  securing  it  by  wra])])in,g  the  two  extremities  of  the  base 
snugly  around  the  limb  and  tying  them.  This  bandage  may  also  be 
employed  on  the  head. 

The  T-bandage  is  used  for  dressings  appHed  to  the  perineum,  the 
horizontal  arm  encircling  the  trunk,  the  perpendicula!r  arm  passing 
between  the  thighs  from  behind  upward  and  fastened  to  the  front  of  the 
body  portion. 

The  Elizabeth  Trotter  many-tailed  abdominal  bandage,  as 
recommended  by  Brockman,  is  applied  as  follows:  Unroll  the  bandage 
enough  so  the  middle  strip  will 
come  just  under  spine  and  par- 
allel with  it,  then  let  each  end 
drop  over  the  side  of  the  table 
as  it  unrolls.  Begin  at  the  top 
on  one  side  and  bring  the  up- 
per tail  across  body  at  a  slight 
angle  with  the  body,  then  bring 
the  top  one  from  the  opposite 
side  over  and  across  it  at 
same  angle. 

Then  proceed  the  same 
with  each  succeeding  pair  of 
tails  till  they  are  all  on.  One 
or  two  safety-pins  will  fasten 
the  last  ones  and  they  will  bind 
or  hold  in  position  all  the  rest 
of  the  bandage.  The  ad- 
vantage of  this  form  of  band- 
age is  that  it  will  fit  any  form 
of  abdomen  and  fit  it  perfectly. 

The  many-tailed  bandage 
is  useful  for  almost  any  part  where  dressings  are  frequently  changed. 
It  is  particularly  serviceable  when  a  firm  abdominal  binder  is  required 
and  in  breast  amputations. 

The  two-tailed  jaw  bandage  is  useful  for  holding  the  lower  jaw 
firmly  against  the  upper,  as  in  fractures  of  the  lower  jaw  or  in  wounds  of 
the  chin. 

The  sling,  to  support  the  forearm  and  arm,  is  made  by  fold- 
ing a  large  piece  of  muslin  into  a  triangle.     Place  the  two  extremities 


Fig.  19. — Sodium  Silicate  Dressixg. — {Hare.) 


122 


POSTOPERATIVE    TREATMENT. 


of   the  base-line  around   the  neck    and   allow  the   forearm  to  rest   in 
the  loop. 

The  Sling  and  Chest-binder. — This  is  a  very  useful  bandage  for 
fixing  the  arm  to  the  chest,  and  is  used  in  fractures  of  the  clavicle  and 
humerus,  injuries  to  the  shoulder  and  elbow.  Place  one  extremity  of  a 
triangular  sling  in  place  around  the  neck,  flex  the  elbow,  and  place  the 
forearm  across  the  chest ;  then  apply  a  chest-binder  including  the  upper 
arm,  and  fix  with  safety-pins,  after  which  the  other  extrernity  of  the  sling 
is  folded  around  the  forearm  and  carried  upward  around  the  neck  and 


Fig.  20. — The  Many-tailed  Abdominal  Bandage. 


tied  to  the  one  already  in  place;  fasten  all  these  layers  together  with 
safety-pins. 

Adjuncts  to  Postoperative  Treatment. — Of  the  many  modern 
appliances  invented  for  the  comfort  and  management  of  patients,  we 
can  refer  to  but  few,  and  that  briefly.  Many  of  these  inventions 
are  not  perhaps  actually  necessary,  yet  they  prove  of  value  in  so  much 
that  they  contribute  materially  not  only  to  the  comfort  of  the  patient,  but 
simplify  and  facilitate  the  after-care,  and  should  therefore  be  obtained 
when  possible. 

The  fracture-bed,  especially  for  use  after  compound  fractures,  is 


ADJUNCTS    OR    AIDS    IN    POSTOPERATIVK   TRKA'IMKNT.  1 23 

now  almost  indispensable.     There  arc  several  varieties  or  patterns,  all 


Fig.  21. — Munger's  Invalid  Bed.     With  Mattress  Raised  to  Semi-sitting  Pos- 
ture AND  Bedpan  in  Place  for  Use. 


Fig.  22. — Munger's  Inv^alid  Bed. 


of  which  have  proved  exceedingly  useful.     Fig.  21  illustrates  Plunger's 
invalid  or  fracture-bed.     Fig.  22  illustrates  the  mechanical  adjustment. 


124 


POSTOPERATIVE    TREATMENT. 


The  mechanism  of  the  fracture-bed  permits  elevation  of  the  head  and 
trunk  to  a  sitting  position  without  disturbing  the  fracture.  To  the  seat- 
board  are  attached  two  Hmb  supports,  each  working  independent,  and  so 


Fig.  23. — Crosby's  Invalid  Bed. 


situated  that  one  or  both  of  the  lower  limbs  may  be  placed  at  any  desired 
height  without  regard  to  the  position  of  the  patient's  trunk.  A  longi- 
tudinal central  slit  in  the  hair  mattress  permits  the  introduction  of  a 

bedpan,  and  thus 
avoids  lifting  or  ele- 
vating the  hips. 

The  Crosby  in- 
valid BED,  which  is 
popular  in  some  hos- 
pitals, is  illustrated  by 
Fig-  23. 

"Michael 

hospital 

is  shown  by 

It    is    of 


The 

Reese 
lifter" 
Fig.    24. 


great  utility  in  the 
treatment  of  various 
complications.  This 
device  is  indicated  for 
use  in  cases  in  which 
it  is  desired  to  raise  helpless  patients  from  a  bed. 

The  '  apparatus   is  weh  shown  in  the  illustration,    and  is  of  such 


Fig.  24.^ — Lifter  for  Raising  or  Lowering  Patient. 


ADJUNCTS   OR   AIDS.  IN   POSTOPERATIVE   TREATMENT. 


I2C 


construction   that  by  means  of  a  crank  and  gcarcrl  mechanism  a  pa- 
tient of   any   weight  may  be  lifted  either  for  the  jjurpose  of  rest  or 
transfer  to  another  bed. 

Sick-bed  Chair.— Among  the  recent  inventions  of 
great  utility  is  that  of  Moore's  sick-bed  chair.  By  its 
use  but  one  attendant  is  required,  and  the  patient  can 
be  handled  with  ease  and  comfort.  The  following  cuts, 
Figs.  25,  26,  and  27,  illustrate  the  method  and  manner 


Fig.  25. — Moore's  Sick-bed  Chair. 


THE  KNY-SCHE:Efi£KCC.N> 


Fig.  26. — Moore's  Bed  Chair — Patient  in  Reclining  Position. 


126 


POSTOPERATIVE    TREATMENT. 


of  usage.     It  is  not  only  useful,  but  is  highly  appreciated  by  patients, 
owing  to  its  simplicity  and  efficiency. 

It  is  made  of  light  wood  and  folds  into  a  compact  form,  and  by  ele- 
vating slightly  or  turning  the  patient  partly  upon  the  side  can  be  easily 
placed  into  position.  The  patient  may  then  be  elevated  to  the  sitting 
position  if  necessary,  with  little  exertion  on  the  part  of  the  attendant. 


Fig.  27. — Moore's  Bed  Chair — Patient  in  Erect  Position. 

The  illustrations  explain  the  apparatus  more  fully  than  any  lengthy 
description  would. 

The  medico-mechanical  massage  apparatus,  as  illustrated  in 
Figs.  28,  29,  and  30,  is  a  very  valuable  adjunct  in  the  after-treatment  of 
dislocations  and  fractures,  for  the  correction  of  joint  motion  or  muscular 
impairment.  This  apparatus  is  used  in  many  of  the  European  clinics. 
It  is  so  constructed  as  to  allow  natural  movements  of  the  various  joints 
and  muscles,  and  is  regulated  by  weights  or  counterbalances.     These 


ADJUNCTS    OR    AIDS    IN    POSTOPF.RATIVK    TRKATMENT.  I27 


Fig.  28. — Medico-mechanical  Apparatus. 


Fig.  29. — Medico-mechanical  Apparatus,  as  Applied  for  Ankylosis  of  the 

Knee. 


128 


POSTOPERATIVE    TREATMENT. 


may  be  so  graduated  as  to  conform  to  the  amount  of  action  or  motion 
of  any  joint  or  muscle;  for  instance,  with  a  patient  suffering  from  partial 
ankylosis  of  th-e  knee  with  only  a  slight  movement  of  the  joint,  the  appar- 
atus is  so  adjusted  to  the  limb  to  suit  the  requirements  of  the  case,  and  so 
that  the  limb  can  be  carried  but  little  beyond  the  point  of  resistance. 
Continued  use  gradually  increases  the  action  of  the  joint  movement, 


Fig.  30. — Medico-mechanical  Apparatus,  Adjusted  for  Ankylosis  of  the  Elbow. 


finally  effecting  complete  restoration.  The  great  value  of  the  apparatus 
lies  in  the  fact  that  the  treatment  on  the  part  of  the  patient  is  self- induced. 
The  cuts  fully  illustrate  the  method  of  application  of  its  various  attach- 
ments. 


CHAPTER  VII. 
HEALING  OF  GRANULATING  WOUNDS. 


CHAPTER  VII. 

HEALING  OF  GRANULATING  WOUNDS. 

Healing  of  Granulating  Surfaces.— The  process  of  repair  upon 
granulating  surfaces,  the  manner  through  which  heahng  is  produced, 
and  the  best  means  needful  for  local  treatment,  is  still  an  open 
question,  as  shown  by  the  different  methods  employed  by  surgeons  at 
the  present  time.  All  agree  that  physiologic  rest  is  the  essential  feature 
in  the  treatment;  i.  e.,  complete  repose,  obtained  through  the  application 
of  proper  splints,  confinement  in  bed  when  necessary,  and,  lastly,  the 
aseptic  and  antiseptic  protection  of  the  granulating  surfaces.  In  the 
healthy  or  normally  healing  surfaces  but  little  treatment  is  necessary, 
except  protection  of  the  surfaces,  prevention  of  external  irritation,  etc. 
When  temporary  sloughing  or  unhealthy  healing  becomes  manifest, 
various  stimulating  agencies,  such  as  silver  nitrate,  zinc  chlorid,  and 
balsam  of  Peru  are  applied  to  stimulate  or  spur  sluggish  granulation. 
Aqueous  solutions,  if  mild  and  nontoxic,  permit  easy  and  efficient  wash- 
ing of  the  surfaces.  Balsamic  preparations  are  of  use  in  specific  forms 
of  ulcers.  The  dressing  which  adapts  itself  most  perfectly  to  the  factor 
of  rest  and  asepsis  is  the  best  possible  treatment  for  acute  granulating 
wound- surfaces.     (Kocher.) 

To  subject  the  surfaces  of  granulated  wounds  to  the  action  of  chem- 
ical irritants,  hydrogen  dioxid,  mercuric  chlorid,  carbolic  acid,  etc.,  is 
harmful  rather  than  useful,  owing  to  their  tendency  to  destroy  the  delicate 
granulations  and  new  epithelium.  The  skilful  management  of  granu- 
lating wounds  requires  long  training  and  a  knowledge  of  the  pathology 
of  repair.  As  a  stimulant  to  unhealthy  granulating  surfaces,  the  use  of 
gold-beater's  skin,  as  suggested  and  prepared  by  Outten,  of  St.  Louis, 
has  proved  of  such  great  value  in  our  hands  in  prolonged  aggravating  or 
unhealthy  granulating  surfaces  that  I  give  herewith  his  method  in  detail : 
"Large  and  perfectly  cleaned  sheets  of  gold-beater's  skin  are  selected. 
The  sheets  are  put  in  hot  sterilized  (not  boiling)  water,  sufficiently  hot 
not  to  interfere  with  the  texture  of  the  skin,  from  98°  to  100°  F. — a 
stream  of  hot  water  preferred.     After  having  remained  in  the  hot  water 

131 


132 


POSTOPERATIVE    TREATMENT. 


sufficiently  long  to  cleanse  them,  they  are  then  taken  therefrom,  and 
squeezed  as  free  from  water  as  possible.  A  solution  is  now  ready,  made 
of  the  following  agents: 

Cobalt  chlorid, i  ounce. 

Gold  chlorid, i  dram. 

Distilled  water, lo  drams. 

The  skins  are  now  put  in  this  solution  so  that  it  entirely  covers  the 
skin  in  any  container  that  may  be  used.  After  the  skins  have  been  put 
in  the  container  holding  the  gold-cobalt  solution,  two  ounces  of  the 
oil  of  cinnamon  is  poured  in  on  the  skins  now  immersed  in  the  gold- 
cobalt  solution. 

"The  sheets  of  gold-beater's  skin  thus  prepared  are  kept  in  a  wide- 
mouthed,  glass- stoppered  container,  immersed  in  the  chemical  solution 
of  oil  of  cinnamon,  as  above  mentioned.  When  the  membranes  are  used 
upon  a  granulating  surface,  the  following  is  the  method  indulged  in:  A 
piece  of  the  treated  membrane  of  sufficient  size  to  well  cover  the  entire 
granulating  surface  is  cut.  This  piece  is  appKed  to  the  granulating  sur- 
face after  the  following  course  is  pursued.  It  is  put  in  alcohol  and  al- 
lowed to  stay  in  the  alcohol  from  three-quarters  of  an  hour  to  an  hour. 
It  is  then  taken  out  of  the  alcohol  and  put  into  hot  water  from  98°  to  100° 
F.  The  membrane  is  put  in  the  alcohol  for  the  purpose  of  removing 
any  excess  of  the  oil  of  cinnamon,  thus  preventing  heat  and  pain  likely 
to  come  from  the  irritating  stimulation  of  the  cinnamon  oil.  After  the 
membrane  has  remained  in  alcohol  sufficiently  long,  and  then  put  into 
the  water  to  remove  the  excess  of  alcohol,  the  skin  is  dried  by  putting 
it  between  the  layers  of  a  sterilized  towel  or  cloth.  A  few  punctures  are 
made  through  the  membrane,  which  is  now  applied  to  the  granulating 
surface.  The  membrane  thus  applied  is  now  covered  with  six  or  eight 
layers  of  sterilized  gauze.  Another  piece  of  membrane  is  then  applied 
on  top  of  the  gauze  large  enough  to  strain  the  air  in  its  access  to  the 
wound.  The  membrane  thus  applied  on  the  sterilized  gauze  need  not  be 
put  in  the  alcohol,  but  simply  squeezed  between  the  folds  of  a  cloth  to 
remove  the  excess  of  the  solution  contained  on  the  membrane.  Now 
there  is  put  on  this  membrane  a  layer  of  sterilized  cotton,  and  then  a  re- 
taining bandage  is  applied.  It  is  thus  seen  that  a  needed  and  well-timed 
discipline  is  here  indulged  in  for  the  application  of  the  gold-cobalt 
membrane.  The  dressing  thus  applied  to  the  granulating  surface  is 
allowed  to  remain  intact  for  at  least  forty-eight  hours. 


HEALING   OF   GRANULATING   WOUNDS,  1 33 

"After  the  first  application  of  the  gold- cobalt  membrane  to  granu- 
lations they  assume  a  bright,  vivid,  healthy  hue  (bright  as  blood  can 
make  them),  looking  firm,  erect,  even,  and  healthy.  Besides  this,  the 
epithelial  border  appears  to  be  stimulated  in  a  remarkable  manner.  It 
is  readily  demonstrable  that  after  the  application  of  the  gold-cobalt 
membrane  a  minimum  amount  of  interference  with  the  granulating  sur- 
face is  obtained.  There  is  no  necessity  of  friction  in  cleansing  the 
surface,  as  when  unguents  are  used.  The  lightest  touching  of  the  granu- 
lating surface  when  cleansing  seems  to  be  sufficient. 

"As  an  aid  in  the  perfect  establishment  of  skin-graft  it  is  an  ideal 
method,  whether  we  use  it  in  the  Reverdin  or  Thiersch  method.  In  the 
Thiersch  method,  when  used  with  the  membrane,  every  graft  appears  to 
live  and  flourish.  When  the  Thiersch  method  is  used,  the  granulating 
wound-surfaces  and  grafts  are  prepared  with  the  saline  solution,  as  is 
usually  done.  The  gold-cobalt  membrane  is  put  in  alcohol  the  same  as 
in  the  treatment  of  granulating  wounds.  It  is  washed  out  with  hot 
water,  and  then  put  into  the  normal  saline  solution  until  it  is  thoroughly 
soaked  and  permeated.  After  the  grafts  have  been  applied  to  the  granu- 
lating surface,  from  one  to  four  perforated  gold-cobalt  membranes  are 
applied.  I  generally  apply  two  membranes,  and  after  forty-eight  hours, 
upon' examination,  the  grafts  will  be  found  in  a  healthy  condition  and 
adherent  to  the  granulation.  The  salt-water  gold-cobalt  membrane 
is  again  applied  for  another  forty-eight  hours.  After  this  time  the  regu- 
lar alcohol-treated  membrane  surface  may  be  applied.  When  these 
grafts  are  applied  upon  a  fresh  curetted  surface  with  treated  membranes 
in  position,  great  impetus  to  the  healing  process  is  manifest." 

SKIN-GRAFTING.* 

When  the  removal  or  destruction  of  integument  has  been  so  extensive 
that  cicatrization  cannot  be  effected  on  account  of  the  tension  of  the  parts 
involved,  skin-grafting  should  be  practised.  There  are  three  recognized 
methods — grafting,  sliding,  and  transplantation  in  mass.  Sliding  and 
transplantation  in  mass  are  usually  performed  at  the  time  of  the  opera- 
tion. As  skin-grafting,  however,  is  frequently  a  postoperative  measure, 
the  ordinary  technic  is  described  in  detail.  There  are  two  recognized 
methods  of  skin-grafting,  known  as  Reverdin' s  "epidermis-grafting"  and 
Thiersch's  "skin-grafting." 

*  Abstract  from  Cheyne's  "Manual  of  Surgical  Treatment,"  Lea  Bros.  &  Co. 


134  POSTOPERATIVE    TREATMENT. 

In  Reverdiu's  method  small  thin  portions  of  the  superficial  layer 
of  the  skin-  are  snipped  off  with  curved  scissors.  Pieces  about  the  size  of 
a  hempseed  are" planted  on  the  surface  of  the  granulations  at  short  dis- 
tances from  each  other;  epidermic  growth  occurs  from  each  of  these  little 
points,  and  the  result,  is  that  numerous  small  islands  of  epithelium  form 
over  the  surface  of  the  sore.  If  the  grafts  are  close  enough  together  and 
the  other  conditions  of  healing  are  favorable,  these  islands  of  epidermic 
growth  soon  coalesce,  and  in  this  way  rapid  cicatrization  is  obtained.  It 
is  necessary  that  these  grafts  should  not  be  too  far  apart,,  because,  as  a ' 
rule,  they  have  only  a  limited  power  of  reproduction.  Usually  each 
graft  gives  rise  to  an  island  of  epidermis  about  the  size  of  a  sixpence,  and 
then  growth  seems  to  come  to  a  standstill.  The  result  of  this  method  of 
epidermis-grafting  is  that  rapid  healing  is  obtained  in  many  cases,  more 
especially  in  burns  and  sores  on  the  trunk,  where  the  skin  is  freely  mov- 
able over  the  deeper  parts.  Further,  the  contraction  of  the  subsequent 
cicatrix  is  considerably  diminished,  because  less  granulation  tissue  is 
formed  than  if  the  sore  has  to  heal  altogether  from  the  margin,  and  the 
amount  of  contraction  depends  entirely  on  the  amount  of  young  granula- 
tion tissue  produced.  Nevertheless,  a  considerable  amount  of  contrac- 
tion will  inevitably  occur  when  healing  has  been  obtained  in  this  way, 
and  the  resulting  scar  is  not  materially  stronger  than  that  obtained  by 
permitting  the  sore  to  heal  from  the  edge. 

Thiersch's  Method. — With  a  view  to  obtaining  a  sounder  scar,  much 
more  extensive  and  thicker  portions  of  the  skin  must  be  taken,  and  the 
grafts  must  be  applied  close  together.  This  is  known  as  Thiersch's 
method.  In  this  method  the  skin  which  is  to  be  used  for  the  graft- 
ing must  first  be  thoroughly  disinfected  in  the  usual  manner,  namely, 
by  turpentine,  soap,  and  strong  mixture,  and  it  must  also  be  carefully 
shaved.  The  presence  of  hairs  on  the  grafts  seems  to  interfere  materi- 
ally with  their  union.  The  skin  of  the  front  of  the  thigh  or  the  flexor 
surface  of  the  forearm  is  usually  employed  for  the  purpose. 

Preparation  of  Wound. — (a)  Preliminary. — The  wound  itself 
must  also  be  prepared  beforehand.  It  is  of  no  use  to  graft  a  wound 
which  is  actually  ulcerating;  it  must  be  brought  into  a  healthy  condition, 
and  healing  must  have  commenced  before  grafting  is  likely  to  be  success- 
ful. The  best  criterion  that  healing  is  taking  place  is  the  presence  at  the 
edges  of  the  dry  red  line  which  indicates  recently  formed  epithelium. 
Some  surgeons  wait  for  a  considerably  longer  time  before  grafting,  in 
order  to  get  a  firm  layer  of  granulations,  but  our  experience  is  that,  so 


HEALING    OF    GRANULATING    WOUNDS.  I35 

soon  as  healing  begins  around  the  edge,  the  wound  may  be  safely  grafted 
upon.  A  second  essential  is  that  the  wound  shall  be  aseptic.  If  it  is 
suppurating,  and  the  discharges  are  septic,  the  graft — which  is,  after  all, 
merely  a  piece  of  dying  tissue — will  become  impregnated  with  decompos- 
ing pus,  and  will  rapidly  become  loosened,  die,  and  undergo  decompo- 
sition. The  methods  of  rendering  the  wound  aseptjc  have  already  been 
described. 

(b)  Operative. — With  a  wound  that  is  aseptic  and  beginning  to 
heal,  the  following  is  the  method  of  procedure :  The  patient  having  been 
put  under  an  anesthetic,  the  granulations  over  the  whole  surface  of  the 
wound  are  evenly  scraped  away,  taking  care,  however,  to  remove  only  the 
soft  layer  of  granulations  and  not  to  go  through  the  deeper  one  of  newly 
formed  iibrous  tissue  into  the  fat.  A  surface  is  thus  left  which  is  smooth, 
highly  vascular,  and  firm,  and  consists  of  the  deeper  layers  of  granula- 
tion tissue  which  have  already  become  organized  into  fibrous  tissue. 
One  is  tempted  to  limit  the  skin-grafting  to  the  parts  actually  unhealed, 
but  if  this  is  done  the  result  will,  as  a  rule,  be  very  disappointing,  for, 
while  the  part  that  has  been  grafted  remains  perfectly  sound,  the  margin 
where  spontaneous  healing  has  occurred  is  very  likely  to  break  down, 
and  thus  a  narrow  line  of  ulceration  appears  later  on  at  the  site  of  the  edge 
of  the  wound.  Having  then  removed  the  layer  of  granulations  in  the 
manner  described,  and  cut  away  the  newly  healed  edge  of  the  wound,  the 
next  thing  is  to  arrest  the  bleeding  completely  before  applying  the  grafts. 
This  is  best  done  by  pressure,  but,  if  pressure  is  applied  directly  to  the 
sore  either  by  sponges  or  dressings,  it  will  be  found  that  the  bleeding 
begins  again  when  they  are  removed,  because  they  stick  to  the  raw  sur- 
face. The  best  plan  is  to  interpose  a  piece  of  protective  sterilized  oiled 
silk  covered  with  a  layer  of  dextrin,  which  prevents  adhesion  of  the 
sponges  to  the  sore  and  thus  avoids  a  renewal  of  the  bleeding  on  removal. 
Hence,  when  the  scraping  and  cutting  are  finished,  any  spouting  vessel  is 
clamped,  and  a  large  piece  of  protective  dipped  in  the  i :  2000  mercuric 
chlorid  solution  is  applied  over  the  raw  surface.  Outside  of  this  several 
sponges  are  placed,  and  a  bandage  dipped  in  i :  2000  mercuric  chlorid 
solution  is  firmly  bound  over  them,  or,  if  the  wound  is  small  and  an 
assistant  available,  he  may  apply  the  pressure. 

Cutting  the  Grafts.— While  the  bleeding  is  being  arrested  by 
pressure,  the  surgeon  proceeds  to  cut  his  skin-grafts.  In  Thiersch's 
method  the  grafts  may  be  taken  from  any  part  of  the  body,  but,  as  a  rule, 
they  are  most  conveniently  cut  from  the  front  of  the  thigh.     The  skin 


136  POSTOPERATIVE    TREATMENT. 

having  been  disinfected,  the  surgeon  grasps  the  thigh  from  behind  with 
his  left  hand,  keeping  the  skin  as  tense  as  possible,  and  also  making  it 
prominent  and  flat  by  pushing  the  muscles  and  skin  forward  from  the 
bone.  The  skin  is  further  put  on  the  stretch  vertically  by  an  assistant 
who  pulls  it  upward  at  the  groin  and  downward  at  the  knee.  The  razor, 
which  should  have  a  very  broad  blade,  is  dipped  in  boric  acid  lotion  or 
normal  salt  solution,  and  is  constantly  kept  wet  by  this  solution  while  the 
grafts  are  being  cut,  just  as  in  making  microscopic  sections  of  fresh  tissue. 
If  this  irrigation  is  not  maintained,  the  graft  tends  to  adhere  to  the  razor 
and  may  be  either  partially  or  wholly  cut  through  before  a  sufficient 
length  has  been  obtained.  The  razor  is  made  to  penetrate  through 
about  half  the  thickness  of  the  skin,  and  then,  by  a  lateral  sawing  motion, 
the  grafts  are  cut  as  broad  and  as  long  as  possible.  After  a  little  practice 
it  is  easy  to  cut  grafts  about  two  inches  in  breadth  and  six  or  seven 
inches  in  length.  If  one  graft  is  not  sufficient,  it  is  best  simply  to  slide  it 
off  the  razor  and  leave  it  lying  on  the  bleeding  surface;  in  this  way  it  is 
kept  warm  and  moist.  Some  surgeons  put  the  graft  into  warm  normal 
salt  solution  or  saturated  boric  acid  lotion,  and  it  is  then  said  to  spread 
out  more  easily  afterward,  but  by  the  former  plan  the  tissues  lie  in  their 
own  juices  and  the  cells  are  more  likely  to  retain  their  full  activity. 

Application  of  Grafts. — When  a  sufficient  number  of  grafts 
have  been  cut,  the  bandage,  sponges,  and  protective  are  removed  from 
the  wound,  and  if  bleeding  has  quite  stopped,  as  is  generally  the  case,  the 
grafts  are  applied  to  its  surface.  The  latter  usually  has  a  thin  layer  of 
blood-clot  upon  it,  and  this  should  be  gently  wiped  away.  Each  graft 
is  lifted  with  forceps  or  the  fingers,  and  placed  on  the  sore  with  the  cut 
surfaces  downward,  and  then,  by  means  of  a  couple  of  probes,  the  folds  of 
the  graft  are  carefully  undone,  and  it  is  stretched  evenly  over  the  surface. 
The  grafts  should  overlap  the  edges  of  the  skin  and  also  each  other,  so 
that  no  part  of  the  raw  surface  is  left  exposed,  for  granulations  always 
spring  up  on  the  uncovered  parts,  and  are  apt  to  eat  away  the  grafts  in 
their  vicinity;  furthermore,  a  thin  scar,  which  may  subsequently  break 
down,  is  left  at  these  points.  The  graft  is  always  thinner  at  the  edge 
than  at  the  center,  and  it  is  these  thin  edges  which  overlap  each  other  or 
the  edge  of  the  ulcer;  there  is  no  real  sloughing  of  these  overlapping 
edges. 

Dressings. — In  spreading  out  the  graft  it  will  be  found  that  air- 
bubbles  collect  beneath  it,  and  also  that  some  amount  of  oozing  goes  on, 
and  the  bubbles  and  clot  may  prevent  complete  adhesion  of  the  graft. 


HEALING   OF   GRANULATING   WOUNDS.  1 37 

Hence  the  next  procedure  is  to  get  rid  of  them  by  pressure.  If  that  is 
attempted  by  means  of  sponges  or  the  hands,  the  graft  is  apt  to  be  dis- 
placed. The  following  is  the  best  plan:  Strips  of  protective  about  an 
inch  in  breadth,  and  long  enough  to  overlap  the  edges  of  the  wound, 
purified  in  i :  20  carbolic  lotion  and  subsequently  rinsed  in  boric  acid 
lotion,  are  applied  firmly  over  the  grafted  surface,  beginning  at  the  lower 
part.  Each  strip  should  overlap  the  one  below,  just  as  in  the  case  of 
strapping,  and  they  should  extend  well  on  to  the  skin  at  each  end.  If 
each  strip  as  it  is  put  on  is  grasped  by  the  two  ends  and  firmly  pressed 
down  on  the  limb,  the  pressure  thus  applied  suffices  both  to  expel  the  air- 
bubbles  and  blood,  and  also  to  arrest  further  capillary  oozing.  The 
whole  surface  of  the  skin-grafts  being  thus  covered,  ordinary  sterile 
gauze  wrung  out  of  i :  6000  mercuric  chlorid  solution  is  applied,  with 
salicylic  wool  outside  it.  The  limb  should  afterward  be  placed  upon  a 
splint,  or  at  any  rate  fixed  that  movement  cannot  occur  during  the 
progress  of  healing. 

The  place  from  which  the  grafts  have  been  taken  may  also  be  dressed 
with  the  protective  and  gauze  dressing,  which  need  not  be  disturbed  for 
ten  days  or  a  fortnight.  At  the  end  of  that  time  the  whole  surface  will 
usually  be  healed,  unless  the  razor  has  somewhere  gone  a  little  deeper 
than  is  necessary.  If  healing  is  not  quite  complete,  weak  boric  oint- 
ment may  be  applied.  The  limb  from  which  the  grafts  are  taken  sh-ould 
always,  if  possible,  be  the  same  as  that  on  which  is  the  ulcer  requiring 
grafting;  for  example,  when  the  ulcer  is  on  the  leg,  the  grafts  should  be 
taken  from  the  thigh  of  the  same  side.  Unless  this  is  done,  a  second 
splint  will  be  required  to  fix  the  limb  from  which  the  grafts  have  been 
taken  until  healing  is  complete. 

Changing  First  Dressing. — The  dressing  should  be  left  on  the 
grafted  surface  for  about  five  days ;  in  some  cases  it  may  even  be  left  for 
a  week.  If  the  wound  is  aseptic,  no  suppuration  or  decomposition  takes 
place  beneath  it.  While  removing  the  dressing,  it  should  be  thoroughly 
soaked  with  a  i :  2000  mercuric  chlorid  solution,  for  the  protective  may 
stick  at  the  edge  and  adhere  to  a  graft,  which  may  thus  be  peeled  off  un- 
less great  care  is  taken.  The  parts  should  be  gently  cleansed  with  a 
1 :  2000  mercuric  chlorid  solution,  and  it  is  best  to  re-apply  the  protective 
and  gauze  dressing  for  about  another  week.  At  the  end  of  that  time  the 
grafts  are  fairly  firmly  adherent,  and  then  a  mild  antiseptic  dressing 
should  be  applied. 

After-treatment. — It  will  be  found  that,  even  at  the  first  dressing 


138  POSTOPERATIVE    TREATMENT. 

the  grafts  present  a  pink  color  and  are  adherent  to  the  deeper  surface, 
though  they  are  still  readily  detached.  In  the  course  of  about  a  week  the 
old  epidermis  peels  off,  but  no  raw  surface  is  left.  Later  on  there  is  a 
great  tendency  to  the  formation  of  new  epithelium,  cornifications,  and 
drying  up,  and  it  is  in  avoiding  the  latter  condition  that  ointments  are  so 
useful.  In  fact,  till  the  scar  is  absolutely  sound  it  is  well  to  keep  the  sur- 
face covered  with  oily  application,  the  best  being  sterilized  cosmolin. 
(Cheyne,  "Manual  of  Surgical  Treatment,"  Lea  Bros.  &  Co.) 

Transplantation  in  mass  is  a  method  not  elaborated  upon  by 
Cheyne,  and  it  appears  to  have  been  first  used  by  Wolfe,  of  Glasgow,  and 
later  revived  by  Krause.  It  consists  in  removing  the  entire  thickness  of 
the  skin  at  a  point  distant  from  the  granulating  surface  to  be  covered. 
The  area  of  the  skin-mass  must  be  from  one-sixth  to  one-third  larger 
than  the  granulating  surface  to  be  covered,  must  have  been  shaved  and 
thoroughly  disinfected  before  removal,  and  contain  no  particles  of  subcu- 
taneous fat.  Sutures  are  not  employed,  and  the  after-treatment  is  prac- 
tically the  same  as  in  the  Thiersch  method,  except  that  should  blebs  form 
on  the  transplanted  skin  they  are  to  be  opened.  Cicatricial  contraction 
is  not  marked  after  the  transplantation  method,  but  the  fact  that  it  in- 
volves a  more  formidable  operation  and  leaves  a  large  granulating 
wound  where  the  skin  was  removed  detracts  from  its  value  as  compared 
with  other  methods. 

A.  B.  Craig,  of  Philadelphia,  has  shown  ("American  Medicine")  the 
value  of  Cargile  membrane  in  skin-grafting,  particularly  by  the  Reverdin 
method.  He  applies  the  grafts  in  the  ordinary  manner,  and  covers  the 
entire  field  with  a  sheet  of  Cargile  membrane.  Dry  sterile  dressings  are 
placed  over  this  and  a  firm  bandage  applied.  If  the  granulating 
surface  is  old  and  the  skin-edges  thickened,  strapping  is  resorted  to,  the 
adhesive  strips  being  applied  over  the  sterile  dressings,  and  a  bandage 
covers  the  whole.  In  any  event  the  dressing  is  carefully  removed  within 
forty-eight  hours,  when  it  will  be  found  that  the  Cargile  membrane  is 
largely  digested.  The  advantage  ascribed  to  the  use  of  the  membrane 
is  that  it  not  only  appears  to  stimulate  epithelial  growth,  but  it  protects 
the  delicate  grafts  for  a  number  of  hours,  and  is  gradually  digested  by  the 
granulations,  thus  permitting  the  wound  secretions  to  escape  into  the 
dressings.  This  method  can  be  readily  carried  out  on  ambulatory  pa- 
tients in  dispensary  service,  as  well  as  within  the  hospital  wards. 


CHAPTER  VIII. 
OPERATIONS. 


CHAPTER   VIII. 
OPERATIONS. 

Remarks. — The  consideration  of  the  after-treatment  of  all  operations 
would  require  much  repetition,  and  occupy  far  more  space  than  can  be 
given  in  this  work.  I  have  therefore  decided  to  describe  only  those  oper- 
ations which  are  classed  as  general  surgery,  making  no  attempt  to  invade 
the  field  of  the  specialist. 

Postoperative  Treatment  of  Operations  Upon  the  Scalp, 
Removal  of  Sebaceous  Tumors,  Wens,  etc. — In  operations  upon 
the  scalp,  removal  of  sebaceous  tumors,  wens,  etc.,  drainage  is  impera- 
tive. A  small  piece  of  gauze  should  be  inserted  at  the  most  dependent 
portion  of  the  incision,  and  removed  on  the  third  or  fourth  day.  The 
rest  of  the  wound  may  be  united  and  permitted  to  heal  as  rapidly  as  pos- 
sible. Scalp  incisions,  as  a  rule,  heal  rapidly,  and  owing  to  the  abun- 
dant blood-supply,  sepsis  rarely  follows.  Strict  adherence  to  asepsis  and 
the  removal  of  hair  well  from  the  field  of  operation  render  the  after- 
treatment  much  easier.  Dressings  should  be  changed  as  often  as  re- 
quired, and  firm  bandages  applied. 

OPERATIONS  UPON  THE  SKULL  AND  BRAIN. 

General  Remarks. — After  operations  upon  the  skull  or  brain  the 
patient  must  be  kept  quiet  in  a  darkened  room.  Careful  avoidance  of 
all  excitement  and  absolute  isolation  are  imperative.  The  bowels  should 
be  kept  open;  the  use  of  alcohol  or  other  stimulants  is  contraindicated. 
After  trephining,  the  wound  is  usually  treated  after  the  open  method,  i.  e., 
gently  packed  with  aseptic  gauze  and  a  compress  and  bandages  applied. 
Should  inflammation  occur,  it  is  usually  manifest  about  three  or  four  days 
after  the  operation.  Rise  of  temperature  and  other  symptoms  of  infec- 
tion call  for  immediate  change  of  dressing  and  careful  irrigation  of  the 
wound.  If  this  treatment  does  not  sufiice  and  there  are  indications  of 
further  and  deeper-seated  infection,  or  if  abscess  of  the  brain  occurs,  as 
manifested  by  nausea,  vomiting,  irregular  pulse,  and  irregular  chiUs, 
with  pain  in  the  head  (not  necessarily  in  the  wound")   increased  by  per- 

141 


142  POSTOPERATIVE    TREATMENT. 

cussion,  and  especially  if  there  is  a  tendency  to  hebetude,  normal  or  sub- 
normal temperature,  disinclination  to  make  effort,  and  stupor,  an  effort 
should  be  made  to  locate  the  abscess  and  evacuate  the  pus.  The  abscess 
cavity  should  be  thoroughly  cleansed  with  sterile  salt  solution  and 
drained  by  gauze  or  tube. 

Complications  Following  Operations  on  Brain. — Secondary 
Meningitis. — Secondary  meningitis  by  extension  of  the  septic  condi- 
tion from  the  seat  of  operation  sometimes  occurs,  indicating  during  con- 
valescence a  failure  to  keep  the  wound  clean.  Veins  or  lymphatics  may 
carry  an  infected  clot  to  the  meninges,  or  the  infection  may  be  carried  by 
direct  continuity  of  tissue.  A  meningitis  following  an  operation  upon 
the  skull  or  brain  will  be  most  pronounced  in  the  vicinity  of  the  incision, 
but  when  once  inflammation  arises,  there  will  be  cloudy  or  purulent 
cerebrospinal  fluid,  with  exudation.  Constitutional  sepsis  is  a  rapid 
sequel  of  meningitis  in  most  cases.  It  may  extend  not  only  to  the  base  of 
the  brain,  but  to  the  spinal  meninges.  The  ordinary  clinical  symptoms 
of  weak  rapid  pulse,  elevated  and  variable  temperature,  delirium,  hyper- 
esthesia of  the  surface,  restlessness,  retained  urine,  constipation,  intense 
headache,  glistening  eyes,  trembling  and  busy  hands,  followed  by  stupor, 
hebetude,  contracted  pupils,  which  often  do  not  react  to  light,  make  up  a 
picture  which  admits  of  little  doubt.  Should  meningitis  be  more  pro- 
nounced along  the  fissure  of  Rolando,  local  spasms  or  paralyses  are  to  be 
expected.  The  results  of  treatment  are  not  favorable.  Attention  to  the 
secretions,  rest,  removal  of  all  exciting  causes,  the  application  of  an  ice- 
bag  to  the  head,  cool  sponging  if  the  temperature  is  high,  strychnin  to 
support  the  pulse,  will  probably  be  all  that  is  to  be  done.  The  free  open- 
ing of  the  wound  and  an  attempt  to  obtain  drainage  are  often  followed  by 
good  results.  It  is  frequently  impossible  to  arrest  the  inflammation,  but 
this  much  is  certain,  that  when  inflammation  occurs  in  a  closed  cavity, 
it  is  always  important  to  have  the  cavity  opened,  so  that  the  products  of 
inflammation  may  find  an  exit  and  tension  be  relieved.  After  trephining, 
in  case  a  fissure-fracture  has  traveled  to  the  base  of  the  skull,  basilar 
meningitis  is  very  likely  to  follow,  and,  since  many  important  cranial 
nerves  are  given  off  from  this  part  of  the  brain,  a  disturbance  of  their 
functions  will  be  noted.  However,  the  inflammation  is  rarely  limited  to 
the  base  of  the  skull,  but  extends  to  the  upper  part  of  the  spinal  meninges 
and  so  retraction  of  the  head  and  interference  with,  and  disturbance  of, 
the  upper  spinal  muscles  are  likely. 

When  there  has  been  any  evidence  of  extension  of  the  inflammation  to 


OPERATIONS, 


143 


the  spinal  meninges,  spinal  puncture  or  laminectomy  may  be  resorted  to, 
with  irrigation;  but  the  results,  up  to  the  present,  of  either  of  these  pro- 
cedures do  not  warrant  great  hopes  of  recovery.  (Abstract  from  Warren- 
Gould.) 

Postoperative  Hernia  Cerebri. — Postoperative  hernia  cerebri  is 
an  evidence  of  sepsis,  local  perhaps.  The  protruding  mass,  which  is 
brain-substance,  at  first  is  small;  but  subsequently  may  become  large, 
may  slough,  may  suppurate,  but  always  projects  above  the  level  of  the 
skull.  It  will  pulsate  and  is  soft  to  the  touch — not  vascular,  however;  it 
is  possible  to  cut  away  portions  of  the  hernia,  for  brain-substance  is  in- 
sensitive. When  portions  of  the  hernia  are  cut  away,  new  portions  are 
apt  to  protrude  through  the  skull.  As  inflammation  diminishes,  the 
hernia  will  sink  within  the  head  and  cicatrization  take  place,  or  the  pa- 
tient may  die  of  general  sepsis. 

Treatment. — An  attempt  to 
force  the  brain  back  into  the 
skull  will  give  rise  to  symptoms 
of  compression  not  advanta- 
geous to  the  patient.  Cutting 
off  pieces  of  the  brain  down  to 
the  level  of  the  skull  is  not 
called  for.  A  clean  dressing, 
with  a  light  compressing  band- 
age to  hold  the  dressings  in 
place,  and  so  exercise  a  very 
slight  pressure  on  the  hernia,  is 
all  that  is  necessary.  The  surface  of  the  hernia  may  slough,  and  if  so, 
the  dressing  should  be  changed  and  cleanliness  continued.  As  the 
wound  becomes  clean  and  cicatrization  takes  place,  the  hernia  will 
disappear.     (Warren-Gould.) 

Trephining. — Closure  or  the  Wound. — The  flap  of  dura  is 
brought  into  place,  and  is  secured  to  the  unwounded  part  of  the  mem- 
brane by  a  few  fine  catgut  sutures;  space,  however,  must  be  left  for 
drainage.  The  trephine  disc  or  any  large  fragment  of  bone  which  has 
been  preserved  may  be  replaced  as  nearly  as  possible  in  situ.  Incase 
the  bone  is  not  replaced,  as  it  is  in  the  osteoplastic  flap  of  Wagner, 
and  it  is  desired  that  the  bony  skull- wall  shall  be  restored.  Keen,  in 
cltan  cases,  preserves,  in  warm  salt  solution,  the  bits  of  bone  removed  by 
the  rongeur  forceps,  and  when  the  dura  is  closed  he  "sows"  these  frag- 


FiG.  31. — Hernia  Cerebri. — {Bryant.) 


144  POSTOPERATIVE    TREATMENT. 

ments  on  the  dura,  like  a  thin  layer  of  gravel,  and  then  closes  the  scalp 
over  this..  This  brings  about  restitution  of  the  bony  wall.  The  replacing 
of  the  trephine-  disc  or  of  large  fragments  of  bone  is  not  necessary,  and 
should  be  resorted  to  only  when  the  portion  removed  is  very  large  and 
when  the  scalp  at  the  time  of  the  operation  is  intact.  Such  replacing 
of  portions  of  bone  should  not  be  practised  in  cases  of  compound 
fracture,  as  infection  is  more  than  probable. 

The  flap  or  flaps  of  scalp  are  now  brought  into  place  by  "silkworm-gut 
sutures,  and  drainage  is  secured  by  introducing  a  bunch  of  horsehair 
threads  here  and  there  between  the  stitches  or  by  a  slight  gauze  drain. 
The  skin  is  well  cleansed,  the  wound  is  dusted  with  iodoform,  and  a  suit- 
able dry  dressing  is  applied  and  is  secured  by  means  of  a  tight  flannel 
bandage. 

After-treatment  of  Cases  of  Trephining. — The  patient  is  kept 
absolutely  at  rest,  and  the  room  occupied  should  be  perfectly  quiet.  The 
head  is  kept  a  little  raised.  The  wound  is  dressed  upon  ordinary  surgical 
principles.  In  case  of  fracture,  or  in  case  of  trephining  for  epilepsy, 
etc.,  in  which  no  lesion  of  the  dura  exists,  draining  by  catgut  will  sufflce. 
In  cases  of  trephining  for  the  removal  of  a  brain  tumor,  or  the  evacuation 
of  a  cerebral  abscess,  drainage  with  a  tube  is  necessary.  In  the  former 
case  the  tube  is  retained  for  twenty-four  hours  only;  in  the  latter  it  is 
retained  until  the  abscess  cavity  has  practically  closed,  and  is  shortened 
as  often  as  required.  In  a  few  instances  of  intracranial  suppuration  a 
second  opening  in  the  skull  may  be  necessary  to  insure  perfect  drainage. 

If,  after  the  removal  of  the  drainage-tube  in  any  case  pain  and  throb- 
bing in  the  wound  are  complained  of,  and  if  the  scalp  flap  appears  to  be 
raised  up,  it  may  be  necessary  to  reopen  the  track  of  the  drainage-tube 
to  allow  pent-up  discharges  to  escape.  Sutures  may  be  removed  at  any 
time  after  the  fifth  or  sixth  day,  or  be  retained  as  long  as  appears  needful. 
If  a  hernia  cerebri  form,  it  can  best  be  treated,  so  far  as  my  own  experi- 
ence goes,  by  means  of  a  pad  of  gauze  and  wool,  kept  constantly  wet  with 
absolute  alcohol.  The  surface  of  the  protrusion  hardens  and  forms  a 
species  of  scab  or  cuticle,  which  in  time  becomes  quite  tough,  and  affords 
an  efficient  covering  to  the  exposed  brain.  (See  Hernia  Cerebri.)  The 
patient  will  need  to  remain  in  bed  until  the  wound  is  soundly  healed. 
From  two  to  three  weeks  will  represent  an  average  time.  The  diet  is 
such  as  is  advised  after  any  grave  operation. 

Secondary  or  Postoperative  Hemorrhage. — Hemorrhage  from  the 
brain  tissue  is  seldom  troublesome.      The  arterioles  for  the  most  part 


OPICRATIONS. 


M5 


run  perpendicularly  to  the  cerebral  sui-face.  MV^sl  of  the  bleeding  is 
soon  checked  with  sponge  pressure,  with  ice,  or  by  the  use  of  sterilized 
adrenalin  solution.  The  actual  cautery  should  never  be  employed  to 
arrest  bleeding  from  the  brain.  Extensive  divisions  of  surface  blood- 
vessels may  be  avoided  by  lifting  them  out  of  the  sulci  between  the  con- 
volutions, and  replacing  the  pia  after  the  operation. 

The  treatment  of  bleeding  from  the  venous  sinuses  is  best  controlled 
by  pressure.  • 

Postoperative  Adhesions  in  Brain  Surgery. — Method  of 
Preventing. — One  of  the  most  troublesome  complications  follow^ing 
operations  on  the  brain,  especially  for  therehef  of  epilepsy,  is  the  post- 


FiG.  32. — Resection  of  Skull. — (Binnie 


operative  formation  of  adhesions,  involving  the  cortex  of  the  brain  and 
its  covering  membranes.  The  adhesions  occur  most  frequently  between 
the  dura  and  pia  or  between  the  pia  and  brain-substance,  and  forming 
thus  mar  the  success  of  the  most  brilliant  operations.  Many  devices 
have  been  used  to  prevent  the  formation  of  adhesions;  of  these,  gold- 
foil,  rubber  tissue,  gold-beater's  skin  (Outten),  and  other  like  substances 
have  been  used  with  variable  success.  Thin  metal  plates  of  gold  and  of 
silver  were  popular  for  a  time,  but  are  now  discarded.  In  a  recent  issue 
of  the  "Journal  of  the  x\merican  Medical  Association,"  M.  L.  Harris,  of 
Chicago,  suggests  the  use  of  silver-foil.     He  writes  as  follows : 

"The  best  material  to  be  used  and  the  details  of  technic,  however,  are 
questions  still  to  be  worked  out.     There  are  some  points  which  appear 


146 


POSTOPERATIVE    TREATMENT. 


to  be  well  established.  For  instance,  the  traumatism  incident  to  the 
operation,  should  be  as  slight  as  possible.  A  bone  flap  which  can  be  re- 
placed is  preferable,  when  possible,  to  the  trephine  opening  with  the  bone 
left  out.  Before  the  introduction  of  any  substance  hemorrhage  should 
be  perfectly  controlled  and  all  blood-clots  removed.  The  substance 
should  extend  well  beyond  the  edge  of  the  area  involved  in  the  adhesions. 
There  should  be  no  openings  or  breaks  in  the  substance.  The  material 
must  be  one  which  can  be  sterilized.  The  wound  must  heal  in  a  per- 
fectly aseptic  manner.  The  question  of  material  is  not  so  well  settled. 
Whether  the  organic  substances,  such  as  egg-membrane,  prepared  ox 
peritoneum,  etc.,  will  prove  of  value  remains  to  be  determined.     They 


Fig.  33. — Use  of  Bone  Gouging  or  Cutting  Forceps  After  TREPHiNiNd. — 

{Binnie.) 

have  not  been  used  often  enough  to  relieve  one  of  the  theoretic  doubt 
of  their  efficacy.  Thin  rubber  tissue  has  been  used  a  number  of  times 
with  good  results.  The  author  has  a  patient  who  has  carried  a  good- 
sized  piece  of  rubber  tissue  in  his  skull  for  several  months  with  an  excel- 
lent result.  One  disadvantage  of  the  rubber  is  its  tendency  to  roll  up 
after  it  has  been  inserted.  It  then  not  only  fails  to  fulfil  its  purpose,  but 
may  be  an  actual  cause  of  irritation.  The  author  knows  of  one  unre- 
ported case  in  which  the  rubber,  which  had  to  be  removed  some  months 
after  it  was  introduced,  was  found  rolled  up.  The  rubber  may  also  be 
disintegrated  by  granulations. 

"  Of  the  materials  thus  far  proposed,  the  author  believes  the  thin  foils 
are  the  best,  and  of  these  he  prefers  the  silver-foil.     It  is  thin  and  soft  and 


OPERATIf)NS.  147 

smooth.  It  conforms  to  all  irregularities  of  the  surface;  on  which  it  is 
laid.  As  many  layers  may  be  applied  as  may  be  necessary  to  secure  a 
smooth,  unbroken  surface.  It  is  not  only  tolerated  kindly  by  the  tissues 
but  exerts  a  beneficial  influence  on  granulating  or  healing  surfaces.  The 
foil  may  be  placed  directly  in  contact  with  the  brain-tissue,  between  the 
pia  and  dura,  or  wherever  it  may  be  necessary  to  accomplish  the  jjurpose 
desired. 

OPERATIONS  UPON  THE  JAW. 

Excision  of  the  Superior  Maxilla. — After  removal  of  the 
bone  it  is  essential  that  all  hemorrhage  be  checked,  and  the  periosteal 
flaps  from  the  roof  of  the  mouth  and  front  of  the  bone  be  carefully 
sutured  together,  preferably  with  chromicized  catgut,  and  before  the 
completion  of  any  form  of  resection,  either  of  the  upper  or  lower  jaw, 
the  buccal  mucous  membrane  should  be  accurately  adjusted  if  divided, 
and  deeper  sutures  should  be  carefully  placed.  If  the  nasal  cavity  is 
opened,  the  soft  tissues  should  also  be  carefully  closed  by  sutures.  In  re- 
sections of  the  lower  jaw  when  the  attachments  of  the  geniohyoglossus 
muscles  are  divided  and  the  tongue  tends  to  fall  backward  upon  the 
glottis,  the  tongue  and  muscles  should  be  drawn  forward  and  the  severed 
attachments  sutured  as  far  forward  as  possible  to  the  buccal  and  deeper 
tissues,  after  which  the  wound  should  be  packed  with  gauze  and  drained 
from  the  outside.  This  drainage  may  be  removed  so  soon  as  it  loosens — 
usually  the  third  or  fourth  day. 

After-treatment.^ — The  patient  should  be  well  sustained  by 
careful  liquid  nourishment  for  the  first  forty-eight  hours,  if  necessan,-, 
by  means  of  a  short  esophageal  tube.  Morphin  should  be  admin- 
istered hypodermatically  if  required.  The  gauze  plug  should  not  be 
large  enough  to  bulge  the  cheek  and  cause  a  strain  upon  the  sutures. 
It  should  be  removed  in  twenty-four  hours,  as  it  soon  becomes  offensive 
if  retained.  Every  possible  care  should  be  taken  that  the  mouth  and  the 
wound  cavity  are  kept  clean.  The  patient  should  be  raised  up  in  bed  by 
means  of  a  bed-rest,  so  as  to  facilitate  the  escape  of  discharges.  He 
should  rinse  the  mouth  very  frequently  with  some  antiseptic  solution. 
Carbolic  acid  (i  in  60  or  80)  answers  admirably.  Two  or  three  times 
a  day  also  the  cavity  should  be  well  w^ashed  out  with  a  like  solution  from 
an  irrigator  provided  with  a  wide-mouthed  nozle.  The  surface  wound 
should  be  kept  dry,  and  dusted  with   iodoform.     The  feeding  of  the 


148 


POSTOPERATIVE    TREATMENT. 


patient  is  a  matter  of  the  greatest  importance.  He  may  be  fed  for  the 
first  day  or  two  with  the  esophageal  tube.  Through  this  tube  mihc, 
beaten-up  eggs,  beef-tea,  and  brandy  can  be  administered  as  frequently 
as  desired. 

■  If  necessary,  this  mode  of  taking  nourishment  may  be  supplemented 
by  nutrient  enemas.  So  soon  as  the  patient  can  swallow  food  without 
assistance  the  mouth  must  be  washed  out  each  time  after  food  is  taken. 
The  skin- wound  generally  heals  well,  and  if  no  complications  arise  the 
patient  may  be  up  in  a  week  or  ten  days.     When  the  wound  is  quite 


Fig.  34. — Resection  of  the  Lower  Jaw. — {Dennis.) 

sound,  the  question  of  fitting  an  artificial  palate  or  tooth-plate  has  to  be 
considered. 

Excision  of  the  Lower  Jaw. — After-treatment. — The  general 
features  of  the  after-treatment  have  been  alluded  to  in  dealing  with  the 
upper  jaw.  The  main  difficulty  is  to  keep  the  mouth  sweet.  A  large 
pouch  is  left  in  the  floor  of  the  mouth,  and  in  this  food  and  the  secretions 
of  the  mouth  must  of  necessity  collect,  and  here  they  are  apt  to  decompose. 
If  care  is  not  taken,  this  pouch  becomes  the  seat  of  the  foulest  possible 
sloughs.  It  is  difficult  for  the  patient  to  wash  the  mouth  out  efficiently, 
as  it  is  painful  to  move  the  remaining  portion  of  the  jaw,  or  even  to 


OPERATIONS.  149 

move  the  head.  The  best  wash  is  a  i  percent  or  2  percent  solution 
of  carbolic  acid. 

The  cleansing  of  the  mouth  is  best  effected  by  irrigation.  For  the 
first  few  days — if  possible,  for  the  first  ten  days^ — it  will  be  well  if  the  food 
can  be  administered  through  a  tube,  so  that  none  can  find  its  way  into 
the  mouth.  If  this  is  done,  and  if  the  mouth  is  washed  out  every  hour 
with  a  gentle  stream  from  an  irrigator,  the  parts  can  be  kept  in  excellent 
condition,  and  healing  will  proceed  rapidly.  If  a  drainage-tube  is 
employed,  it  should  be  removed  in  twenty-four  hours,  and  the  escape 
of  the  fluids  in  the  mouth  through  the  skin- wound  should  not  be 
encouraged  after  that  time. 

The  patient  should  occupy  the  sitting  position  as  much  as  possible 
and  every  care  should  be  taken  that  he  is  well  fed.  In  the  manner  of 
feeding  I  have  usually  employed  the  nasal  tube,  which  has  been  passed 
after  a  little  cocain  had  been  introduced  into  the  nose  through  an  atom- 
izer. The  foulness  of  the  mouth  in  a  neglected  case  is  indescribable, 
and  the  persistent  attempt  to  avert  decomposition  is  a  main  element  in 
the  after-treatment.     (Treves.) 

After  partial  resection  of  the  lower  jaw,  a  carefully  padded  and 
adjusted  splint  should  be  applied  to  prevent  movements  of  the  part  and 
keep  the  lower  jaw  in  proper  relation  to  the  upper.  In  section  of  the 
ramus  for  ankylosis  passive  motion  should  begin  the  third  or  fourth 
day  after  the  operation,  and  be  regularly  maintained.  It  is  usually 
necessary  to  use  anesthesia  for  this  purpose.  Relapse  is  ver}'  likely  to 
recur,  however,  unless  the  proper  after-treatment  is  carefully  carried  out. 

EXCISION  OF  THE  TONGUE. 

General  Considerations.  —  Whether  the  operative  method  of 
Whitehead  or  of  Kocher — those  most  commonly  employed — be  fol- 
lowed, after-treatment  is  very  essential. 

Prior  to  the  operation  it  is  essential  to  have  the  teeth,  mouth,  and 
pharynx  thoroughly  cleansed  by  scraping  aw^ay  all  tartar,  by  drawing  all 
bad  teeth,  and  by  cauterizing  all  ulcerating  patches.  Small  abscesses 
and  collections  of  decomposing  matter  in  the  crypts  of  the  tonsils  should 
be  disinfected  after  carefully  slitting  up  their  cavities.  The  avoidance 
of  injury  in  any  manner  to  the  mechanism  of  swallowing  is  also  veiy 
important;  i.  e.,  the  muscles  of  the  floor  of  the  mouth,  tongue,  and 
pharynx,  with  their  nerves  of  supply.     Further,  free  escape  must  be 


15° 


POSTOPERATIVE    TREATMENT. 


given  for  the  discharge  and  secretions  from  the  mouth.  It  is  only  by 
careful  attention  to  these  points  that  the  danger  from  decomposition  of 
the  exudation  from  the  wound  can  be  reduced  to  the  minimum.  It  is 
likewise  essential  that  the  patient  be  placed,  so  soon  as  recovered  from 
the  anesthesia,  in  a  half-sitting  position,  and  so  soon  as  possible  he 
should  assume  the  sitting  posture  or  be  gotten  out  of  bed.  The  method 
which  Kocher  now  employs,  and  which  is  described  in  a  recent  (1903) 
edition  of  his  "Text-Book  of  Operative  Surgery,"  is  a  modification  and 


Fig.  35. — Anatomic  Relations  of  the  Parts  Involved  in  Kocher's  Present  Oper- 
ation FOR  Removal  of  the  Tongue  by  Median  Division  of  the  Lower  Jaw. 
— {Kocher,  "American  Text-Book  of  Surgery.") 
a,  Line  of  division  of  the  mucous  membrane;    b,  lingual  nerve;    c,  lingual  vein; 
d,  lingual  artery;  e,  hyoglossus  muscle;  /,  hypoglossal  nerve;  g,  tongue;    h,  right  genio- 
hyoglossus  muscle;  i,  left  geniohyoglossus  muscle;  k,  geniohyoid  muscle. 


extension  of  the  Sedillot-Syme  operation,  in  which  the  lower  lip  is 
divided  vertically  and  the  symphysis  menti  is  sawed  through,  permitting 
free  access  to  the  floor  of  the  mouth.  Kocher  divides  the  soft  tissue 
backward  to  the  hyoid  bone.     All  vessels  are  ligated  as  they  are  severed 


OPERATIONS.  151 

during  operation.  The  wound  is  closed  by  wiring  the  divided  bone  and 
suturing  the  soft  parts  anteriorly,  but  an  important  point  is  that  thorough 
drainage  is  secured  through  the  lloor  of  the  mouth,  the  gauze  being 
carried  through  the  skin-incision  near  the  hyoid  bone.  The  method  of 
Kocher  has  the  following,  advantages:  the  postoperative  hemorrhage 
is  very  slight  or  more  easily  controlled,  the  secretions  of  the  wound  are 
drained  away  much  more  satisfactorily,  and  preservation  of  the  tissues 
of  deglutition  along  with  their  nerves,  by  which  a  better  functional 
result  is  obtained  than  by  any  other  method.  CThis  preservation  of  the 
powers  of  deglutition  is  of  the  greatest  importance  in  preventing  secon- 
dary pneumonia,  the  great  danger  which  threatens  the  patient.   ) 

Method  of  After-treatment  by  Sir  Frederick  Treves. — "The 
patient  may  be  allowed  up  on  the  third  or  fourth  day,  and  in  the 
majority  of  the  cases  I  have  treated  at  the  London  Hospital  the  patient 
has  left  the  hospital  between  the  seventh  and  the  tenth  day  after  the 
excision. 

"I  have  been  very  much  disappointed  with  a  solution  of  potash 
permanganate  as  a  wash,  and  have  long  since  given  it  up.  Boric  lotion 
is  still  more  ineffective. 

"Some  surgeons,  notably  Woltler,  have  advised  that  the  floor  of  the 
mouth  be  packed  with  iodoform  gauze.  I  have  tried  this  dressing,  but 
cannot  recommend  it.  Mr.  Whitehead  does  not  encourage  his  patients 
to  consider  themselves  invalids.  They  get  up  on  the  day  after  the 
operation,  and  may  on  that  day  take  open-air  exercise.  Food  is  admin- 
istered by  the  mouth  on  the  day  after  the  excision.  In  the  matter  of 
rapidity  of  recovery,  Mr.  Whitehead's  cases  stand  preeminent. 

"Many  American  surgeons  prefer  to  pack  the  floor  of  the  mouth 
with  iodoform  gauze  in  long  strips  which  come  out  through  the  lower  or 
counteropening,  or  through  the  most  dependent  portion  of  the  external 
wound,  w'hich  is  partly  closed,  covered  with  iodoform  gauze,  and  firmly 
bandaged.  By  far  the  best  and  simplest  method,  however,  is  to  place  a 
soft-rubber  drainage-tube  well  into  the  floor  of  the  mouth  and  have  it 
pass  out  the  external  cut  or  wound  at  the  lowest  possible  point.  The 
tube  should  pass  through  the  outer  dressings  of  iodoform  which  are  pro- 
tected from  saturation  by  rubber  tissue.  Over  the  outer  opening  of 
the  drain  tube  is  placed  a  layer  of  absorbent  cotton,  and  over  this  a 
second  or  temporary  bandage.  The  first  or  primary  bandage,  if  applied 
tightly,  adds  much  to  the  comfort  of  the  patient  and  facilitates  swallow- 
ing.    The  drainage-tube  helps  materially  to  keep  the  surface  inside  the 


152  POSTOPERATIVE    TREATMENT. 

mouth  dry  and  clean.  The  mouth  should  be  thoroughly  irrigated  with 
hot  normal  salt  solution  several  times  a  day,  and  the  external  or  tempo- 
rary dressings  should  be  changed  as  frequently  as  necessity  may  require. 
The  after-treatment  in  all  these  cases  or  methods  of  operating  involves 
three  great  factors:  First,  the  patient  must  be  well  fed;  second,  thorough 
drainage  must  be  established  from  the  mouth;  third,  the  cavity  of  the 
mouth  must  be  kept  clean  and  sweet." 

Method  of  After-treatment  by  Kocher. — "Some  surgeons  simply 
dust  the  jfloor  of  the  mouth  with  iodoform.  Others  resort  to  the  objec- 
tionable practice  of  stuffing  the  mouth,  or  at  least  the  lower  segment  of 
it,  with  gauze.  I  have  dispensed  with  applications  of  any  kind.  The 
mouth  is  well  washed  out  with  an  antiseptic  lotion  and  is  left.  It  must 
be  remembered  that  the  discharge  of  saliva  is  fairly  copious,  and  renders 
any  'dressing'  almost  immediately  ineffective. 

"The  patient  is  encouraged  to  sit  up  in  bed  as  soon  as  possible. 
Morphin  should  be  avoided  whenever  it  can  be ;  it  dulls  the  reflex  sensi- 
bility of  the  patient,  and  may  cause  him  to  allow  fluid  to  run  down  into 
the  air-passages. 

"The  patient  must  be  impressed  with  the  importance  of  allowing  all 
discharge  to  escape  from  the  mouth,  and  of  swallowing  none  of  it.  The 
mouth  must  be  kept  constantly  washed  out.  This  rinsing  of  the  mouth 
cannot  be  too  frequently  performed.  Every  half-hour  in  the  day,  and 
three  or  four  times  in  the  night,  is  not  too  often.  The  best  wash  is  car- 
bolic lotion  (i  in  60  to  i  in  80). 

{  "After  certain  of  the  washings,  say,  three  or  four  times  a  day,  the 
floor  of  the  mouth  is  dried  with  a  pledget  of  cotton- wool,  and  iodoform 
is  dusted  over  the  raw  surface.  It  soon  forms  a  more  or  less  consistent 
pellicle  over  the  stump.  A  watch  must  be  kept  for  the  symptoms  of 
iodoform  poisoning.  During  the  first  twenty-four  hours  the  patient  may 
be  fed  by  the  rectum,  and  ice  only  should  be  taken  by  the  mouth.  The  use 
of  ice  should  be  very  moderate,  as  it  does  little  but  fill  the  mouth  with 
fluid,  which  gives  the  patient  some  trouble  to  get  rid  of.  (^t  the  end  of 
twenty-four  hours  the  patient  should  swallow  food.])  It  is  best  given  with 
an  ordinary  feeder,  while  the  man  sits  upright,  with  his  head  inclined  to 
one  side. 

"The  difficulty  of  swallowing  is  usually  overcome  with  a  little 
patience  and  practice.  Should  the  patient  be  quite  unable  to  swallow, 
then  he  must  be  fed  with  an  esophageal  tube.  One  feature  in  the 
after-treatment  of  these  cases  must  not  be  lost  sight  of.  \The  patient 


OPEKATIONS.  153 

must  be  well  jed.X/^^  soon  as  enough  nourishment  is  taken  by  the 
mouth  the  nutrient  enemas  may  be  discontinued .  After  every  occasion 
upon  which  food  is  taken,  the  mouth  must  be  well  washed  out. 

"Now  and  then  the  cavity  may  be  flushed  out  with  an  irrigator. 
These  cases  demand  the  undivided  attention  of  two  nurses,  one  for  day 
and  one  for  night  duty,  for  upon  the  careful  nursing  of  the  case  as 
much  of  the  success  depends  as  upon  the  operation.  J 

"No  drainage  of  the  mouth  cavity  is  needed  in  these  cases.  If  the 
part  becomes  unduly  offensive,  a  stronger  solution  of  carbolic  acid  must 
be  used,  and  the  mere  rinsing  out  of  the  mouth  must  be  replaced  by 
a  flushing  out  of  the  cavity  with  the  irrigator. 

"These  perpetual  washings-out  of  the  mouth  involve  considerable 
annoyance  to  the  patient,  but  they  are  necessary  only  for  a  few  days,  and 
it  must  be  borne  in  mind  that  the  usual  cause  of  death  after  these  opera- 
tions is  septic  pneumonia."   ^ 

CLEFT  PALATE. 

After-treatment  (Cheyne) . — The  patient  is  placed  in  bed  with  the 
head  low  and  turned  to  one  side  so  that  the  blood  may  trickle  out  through 
the  mouth.  There  is  often  a  good  deal  of  shock,  and  the  patient  should 
be  surrounded  with  hot  bottles  or  be  put  upon  a  large  hot-water  pillow. 
Food  should  not  be  given  until  all  danger  of  vomiting  has  ceased,  and  for 
the  first  four  or  five  days  nothing  but  liquids  should  be  taken;  during 
the  first  forty-eight  hours  these  are  best  given  iced.  The  food  should 
consist  of  milk,  milk  and  soda,  or  milk  and  lime-water.  It  is  best  given 
with  a  spoon,  and  later  on  from  a  feeder  furnished  with  an  india-rubber 
tube  which  is  passed  as  far  back  as  possible  at  the  side  of  the  mouth. 
After  the  fourth  day  bread  and  milk,  custards,  arrow-root,  etc.,  may  be 
given,  but  no  solid  food  should  be  administered  for  at  least  ten  days. 

The  most  important  part  of  the  treatment  consists  in  keeping  the 
patient  absolutely  quiet.  Talking,  laughing,  cr}'ing,  etc.,  must  be 
guarded  against  as  effectually  as  possible.  The  hands  should  be  muffled 
if  necessary  and  tied  to  the  side  to  prevent  the  risk  of  the  child  sucking 
the  thumb  or  fingers ;  or  an  eft'ectual  plan,  and  one  that  is  less  irksome 
to  the  child,  is  to  mold  small  splints  of  cardboard  or  felt  along  the  front 
of  the  arm  from  the  middle  of  the  upper  arm  to  the  middle  of  the  fore- 
arm. This  prevents  the  child  flexing  the  elbow;  he  therefore  cannot 
reach  his  mouth,  but  he  can  use  his  arms  and  can  play  with  his  toys,  etc. 


154  POSTOPERATIVE    TREATMENT. 

At  the  end  of  that  time  the  palate  should  be  examined  and  the  stitches 
removed,  at  any  rate  from  the  hard  palate ;  in  order  to  do  this  satisfac- 
torily it  is  well  to  administer  an  anesthetic.  Should  the  union  be  good, 
all  the  stitches  may  be  taken  out  then ;  if  at  any  part  the  union  is  doubt- 
ful, they  should  be  left  in  for  a  few  days  longer. 

Complications. — There  are  two  probable  complications  common 
to  all  operations  for  cleft  palate : 

1.  Bleeding. — As  a  rule,  the  hemorrhage,  though  free  at  first,  is 
easily  controlled  by  gentle  sponge  pressure.  If  it  is  obstinate,  it  gen- 
erally results  from  incomplete  division  of  the  posterior  palatine  artery 
or  some  of  its  branches.  Secondary  hemorrhage  may  also  occur  and 
is  fairly  common  in  weak,  anemic  children  or  in  those  who  are  the 
subject  of  hemophilia. 

Treatment. — This  is  comparatively  simple.  If  the  hemorrhage  is 
troublesome  at  the  time  of  the  operation  and  sponge  pressure  will  not 
stop  it,  the  clots  should  be  carefully  wiped  from  the  region  of  the  lateral 
incisions  and  the  source  of  hemorrhage  exposed.  If  it  comes  from  a 
partially  divided  vessel  at  the  end  of  the  incision,  the  extension  of  the 
incision  will  probably  suffice,  especially  if  combined  with  firm  pressure 
directly  upon  the  bleeding  point  either  with  the  finger  or  a  small  piece 
of  sponge.  The  treatment  of  secondary  hemorrhage  is  sometimes  more 
difficult.  In  the  first  place,  an  attempt  should  be  made  to  check  the 
bleeding  by  syringing  away  the  clots  with  iced  boric  lotion,  and  small 
pieces  of  ice  inclosed  in  muslin  may  be  pressed  against  the  lateral  in- 
cision from  which  the  bleeding  is  coming.  If  this  fails,  an  anesthetic 
should  be  given,  and,  after  the  blood-clot  has  been  cleared  away,  the 
bleeding  point  should  be  exposed.  If  firm  pressure  on  it  is  not  effectual, 
and  if  the  vessel  cannot  be  picked  up  in  forceps  and  tied,  the  bleeding 
will  probably  be  coming  from  the  posterior  palatine  canal,  and  an  at- 
tempt should  be  made  to  stop  it  by  temporarily  plugging  the  canal  with  a 
fine  probe.  If  this  does  not  succeed,  the  canal  may  be  plugged  with 
Horsley's  wax  (see  page  40) . 

2.  Failure  of  Union. — The  other  important  complication  is  failure 
of  union  at  some  part  of  the  cleft.  The  failure  may  be  partial  or  entire. 
It  generally  happens  that  only  one  portion  gives  way,  and  it  is  most  com- 
mon to  find  a  deficiency  either  at  the  extreme  anterior  end  or  about  the 
junction  of  the  hard  with  the  soft  palate.  Nonunion  may  be  due  to  one 
of  three  principal  causes : 

{a)  Imperfect    Operation. — The  cleft  may  be  insufficiently  pared, 


OPERATIONS.  155 

generally  because  each  side  has  not  been  pared  in  a  single  piece  and  thus 
some  part  has  been  overlooked  or  only  a  very  narrow  portion  removerl; 
the  tension  u])()n  the  Haps  may  be  so  great  as  to  interfere  with  union ;  the 
flaps  may  be  brought  badly  into  apposition,  one  edge  being  curled  up  so 
that  the  raw  surfaces  are  not  together;  the  stitches  may  be  tied  either  too 
loosely  or  too  tightly;  or  the  flap  may  be  so  bruised  by  rough  handling 
that  its  vitality  is  seriously  diminished. 

(6)  Iniercurrenl  inflammalory  affeclions,  such  as  a  severe  cold,  the 
onset  of  a  specific  fever,  or  ordinary  septic  infection,  may  entirely  prevent 
union.  Septic  infection  of  the  line  of  incision  is  largely  predisposed  by 
rough  handling  of  the  flaps. 

(c)  Want  of  proper  care  in  the  ajter-treatmeni  may  bring  about  failure 
of  union.  Among  the  most  important  factors  leading  to  failure  of  union 
after  an  otherwise  perfectly  satisfactory  operation  are  excessive  crying, 
vomiting,  or  mechanical  violence  produced  by  hard  food,  fingers,  or  for- 
eign bodies  thrust  against  the  flaps. 

It  is  well  to  remember  that,  unless  union  fails  throughout  the  whole 
palate,  the  gap  left  after  limited  failure  of  union  is  diminished  very  con- 
siderably in  the  course  of  time  by  the  granulations  springing  up  around 
the  hole.     This  is  especially  the  case  in  the  soft  palate. 

Treatment. — The  treatment  in  cases  in  which  union  seems  doubtful 
is,  of  course,  largely  prophylactic,  and  every  precaution  must  be  taken 
in  the  way  of  careful  operation  and  after-treatment  to  see  that  nothing 
interferes  with  union.  Any  intercurrent  affection,  such  as  a  cold,  should 
receive  careful  attention.  If,  when  the  wound  is  examined,  there  be  any 
doubt  as  to  the  amount  of  union  present,  the  stitches  should  not  be  re- 
moved for  a  fortnight  or  three  weeks.  Should  failure  of  union  occur  at 
any  part,  it  is  well  to  wait  until  the  edges  are  freely  granulating,  and  then, 
after  administering  an  anesthetic,  to  introduce  fresh  sutures  and  draw  the 
flaps  together  without  tension.  It  is  not  generally  necessary  actually  to 
pare  the  edges  when  introducing  stitches  for  the  second  time,  although 
it  may  be  advisable  to  scrape  the  granulating  edges  slightly.  These 
second  stitches  should  be  left  in  for  at  least  a  fortnight.  If  this  secondary 
union  fails,  it  is  well  to  delay  further  operative  interference  for  a  period 
of  at  least  six  months,  so  as  to  allow  complete  cicatrization  and  contrac- 
tion to  take  place.  The  subsequent  operation  consists  in  paring  the 
edges  of  the  defect,  making  lateral  incisions  for  the  relief  of  tension,  and 
then  bringing  the  edges  together.  Unfortunately,  if  the  union  fails  in  the 
soft  palate,  the  contraction  leads  to  shortening  of  the  palate,  so  that  sec- 


156 


POSTOPERATIVE    TREATMENT. 


ondary  operations  seldom  avail  to  bring  about  a  perfect  result.  Hence 
every  possible  care  should  be  taken  to  secure  union  in  the  first  operation. 
After-treatment  (Treves). — The  patient  should  remain  in  bed 
for  a  week.  No  food  of  any  kind  should  be  administered  until  all  vomit- 
ing has  ceased.  The  diet  should  be  simple,  and  may  consist  for  the  first 
day  of  milk  or  milk  and  water  only,  and  after  that  of  beef-tea,  broth, 
eggs,  arrowroot,  custard,  and  sago  puddings,  bread  and  milk,  stewed 
fruit,  and  the  like.  Porridge,  pounded  meat,  or  fish  may  be  given  when 
a  few  days  have  elapsed.  Two  mistakes  are  frequently  made  in  the 
after-treatment :   one  is  to  starve  the  patient,  and  the  other  is  to  feed  him 


(^i        ij 


Fig.  36.  Fig.  37. 

Types  of  Cleft  Palate. — {Brewer.) 

SO  frequently  with  small  quantities  of  food  that  the  pharyngeal  muscles 
are  never  at  rest.  One  author,  indeed,  says  that  food  should  be  admin- 
istered ''unceasingly." 

The  patient  should  be  fed  as  an  ordinary  patient  is  fed,  but  the  food 
must  be  fluid,  or  at  least  perfectly  soft,  and  must  be  swallowed  slowly 
and  carefully.  The  pharyngeal  muscles  contract  more  completely 
around  a  small  bolus  than  a  large.  This  simple  and  almost  fluid  diet 
should  be  observed  for  two  or  three  weeks,  until,  indeed,  it  is  clear  that 
the  wound  has  healed  or  has  broken  down  hopelessly.  It  is  well  to  for- 
bid much  talking.  For  the  first  few  days  the  less  the  patient  speaks,  the 
better. 


OPERATIONS. 


157 


One  important  factor  must  not  be  overlooked — the  mouth  must  be 
kept  clean.  It  is  often  rendered  foul  by  decomposing  milk  and  beef-tea, 
which  remain  in  the  recesses  of  the  mouth,  owing  to  the  patient's  exag- 
gerated belief  in  the  evils  which  attend  swallowing.  The  best  wash  is  a 
warm  solution  of  carbolic  acid  (i  in  100  to  i  in  80).  Boric- acid  lotion 
also  answers  well. 

The  mouth  should  be  rinsed  out  after  every  meal,  and  at  other  times 
as  occasion  suggests.  I  am  in  the  habit  of  having  the  wound  washed 
at  least  twice  a  day  with  a  warm  boric-acid  solution,  which  is  applied 
to  the  palate  by  means  of  a  "scent  spray."  It  is  agreeable  to  the  pa- 
tient, and  it  keeps  the  part  free  from  incrustation. 


Fig.  38. 
The  edges  of  the  cleft  are 
being  pared  with  a  probe- 
pointed  bistoury  after  pass- 
ing the  sutures.  It  is  better 
to  pare  the  edges  before 
passing  the  sutures. — Ber- 
nard and  Huette.) 


Fig.  39. 
Method  of  Rink:  The  su- 
tures d  d  and  c  c  in  place,  the 
third,  b,  being  inserted  from 
behind  forward  by  a  curved 
needle-holder,  a;  the  lips  are 
held  tense  with  the  forceps. 
-^{Bernard  and  Huette.) 


Fig.  40. 
The  sutures  being  fas- 
tened, the  lateral  incisions 
a  b  are  made  to  relieve  ten- 
sion by  division  of  the 
tensor  palati  muscles.  — 
{Bernard  and  Huette.) 


The  advice  that  the  palate  in  young  children  should  not  be  inspected 
for  one  week  after  the  operation  is  hardly  consistent  with  the  practice 
which  obtains  in  the  treatment  of  wounds  elsewhere. 

The  sutures  need  not  be  removed  until  fourteen  days  or  three  weeks 
have  elapsed.  Sutures  of  silkworm-gut  and  fine  silver  set  up  singularly 
little  disturbance,  and  may  be  retained  for  weeks,  but  it  is  obvious  that 
if  firm  union  has  not  taken  place  in  three  weeks,  it  will  probably  not  take 
place  in  five. 

Results. — -The  success  of  the  operation  may  be  compromised  by 


158 


POSTOPERATIVE    TREATMENT. 


severe  vomiting,  by  the  swallowing  of  solid  food,  by  the  development  of 
whooping-cough  or  an  eruptive  fever,  or  by  the  feebleness  of  the  pa- 
tient's health.  .  It  must  be  remembered  that  the  closure  of  the  cleft  does 
not  remedy  the  defective  articulation.  The  soft  palate  in  these  cases  of 
congenital  deformity  is  not  only  deficient  in  the  median  line,  but  deficient, 
as  a  rule,  throughout.     It  is  unduly  short,  and  after  the  most  successful 


Fig.  41.  Fig.  42. 

(Malgaigne. — Binnie,  after  Esmarcli  and  Kowalzig.) 


Fig.  43.  Fig.  44. 

Nelaton. — {Binnie,  after  Esmarch  ajid  Kowalzig.) 


Fig.  45.  Fig.  46.  Fig.  47. 

(Binnie,  after  Esmarch  and  Kowalzig.) 


operation  it  is  doubtful  if   the    palate  is  ever  so  completely  restored 
that  it  is  capable  of  shutting  off  the  mouth  from  the  nasal  passage. 

The  operation,  however,  places  the  patient  in  a  position  to  attain 
normal  articulation.  It  enables  him  to  be  educated  to  speak  naturally. 
This  education  is  tedious,  and  involves  a  great  expenditure  of  time  and 
trouble,  but  it  is  remarkable  what  excellent  results  may  follow,  even  in 


OFKKATKJNS.  I59 

cases  which  cannot  be  considered  from  a  surgic-al  j)oinl  of  \'ie\v  to  fje  em- 
inently successful. 

HARE-LIP. 

Operations  Upon  Infants. — So  soon  as  the  bleeding  has 
stopped,  the  line  of  incision  is  painted  with  collodion  and  the  following 
method,  introduced  by  Lord  Lister,  is  of  value  as  a  support  to  the  wound : 
A  double  thickness  of  gauze  is  cut  in  the  shape  of  a  bat's  wing,  one  broad 
surface  lying  over  each  cheek  and  the  narrow  intervening  portion  passing 
across  the  lip.  One  end  of  this  dressing  is  then  fastened  to  the  cheek 
with  collodion,  and,  when  it  is  dry,  the  two  cheeks  are  pushed  forward 
and  held  in  this  position  while  the  other  end  is  fixed  with  collodion  to  the 
other  cheek  and  held  in  position  until  it  is  quite  dry;  in  this  way  all  ten- 
sion is  avoided.  If  the  nostril  is  unduly  small  after  the  stitches  are  put 
in,  it  is  well  to  put  a  small  drainage-tube  in  it  to  leave  breathing  space ; 
fatal  cases  are  recorded  from  the  valve-like  action  of  the  upper  lip  com- 
bined with  the  blocking  of  the  nostrils  by  clot  obstructing  the  breathing. 
In  time  the  nostrils  will  become  quite  patent.     (Treves.) 

After-treatment. — The  stitches  can  usually  be  removed  at  the 
end  of  a  week;  in  fact,  the  horsehair  and  catgut  sutures  may  be  removed 
in  two  or  three  days,  the  deeper  silkworm-gut  stitches  being  left  for  a 
week  or  more.  After  the  operation  the  child  should  be  entirely  fed  by 
the  spoon  with  very  great  care  to  prevent  injury  to  the  line  of  incision; 
the  point  of  the  spoon  should  be  introduced  at  the  side  opposite  to  that 
operated  on.  After  the  wound  has  healed,  the  patient  may  be  put  on  the 
bottle. 

OPERATIONS  ON  THE  NOSE. 

Subcutaneous  Paraffin  Injection. — (Abstract  from  "Progressive 
Medicine,"  March,  1904.) 

The  secret  of  the  postoperative  success  or  failure  of  the  operation 
depends  largely  upon  the  kind  of  parafhn  used  and  the  aseptic  technic 
of  the  procedure.  Perusal  of  the  various  writings  upon  this  subject 
shows  clearly  that  parafihns  having  different  melting-points  have  been 
employed;  thus,  Gersuny  himself  used  white  vaselin  or  the  unguentum 
paraffin,  a  mixture  of  solid  and  liquid  paraffin,  a  substance  having  a 
melting-point  of  97°  to  104°  F.  Objection  has  been  raised  to  the  em- 
ployment of  this  form  of  parafhn  on  the  ground  that  it  remained  liquid 


l6o  POSTOPERATIVE    TREATMENT. 

for  some  hours  after  its  injection  into  the  tissues,  and  therefore  favored 
emboHsm,  also  that  infihration  into  the  neighboring  tissues  is  possible 
after  its  introduction.  It  has  also  been  asserted  that  a  slow  absorption 
of  this  material  is  possible,  and  that  consequently  permanent  improve- 
ment was  not  to  be  expected  from  the  operation. 

Still  another  drawback  presents  itself  in  the  fact  that  the  melting-point 
of  the  vaselin  used  by  Gersuny  was  relatively  about  the  normal  temper- 
ature of  the  human  body,  that  the  individual  might  readily,  under  the 
influence  of  some  marked  feverish  condition,  acquire  a  temperature 
equal  to  or  higher  than  the  melting-point  of  the  vaselin,  the  consequence 
of  which  is  sufficiently  obvious. 

Eckstein,  of  Berlin,  employs  a  solid  paraffin  having  a  high  melting- 
point  of  120°  to  130°  F.  This  substance,  therefore,  has  a  melting-point 
considerably  higher  than  that  of  the  tissues  into  which  it  is  injected.  It 
solidifies  rapidly  and  thus  remains  in  the  same  situation  uninfluenced  by 
muscular  contraction  or  other  forces. 

Broeckaert  has  more  recently  modified  Eckstein's  procedure.  He 
prefers  to  use  a  paraffin  melting  at  56°  C.  Mosckowicz  now  also  injects 
the  unguentum  paraffin  in  a  solid  state.  After  melting  and  drawing  it 
into  the  syringe,  he  there  allows  it  to  cool  down  until  solidification  takes 
place,  and  then  in  the  form  of  a  fine  thread  he  injects  it  into  the  tissues. 
It  is  preserved  in  sealed  bottles  after  the  manner  of  antitoxin  serums. 
The  paraffin  must  be  thoroughly  sterilized,  the  sterilizer  in  which  the 
syringe  is  boiled  also  serving  as  a  water-bath  in  which  to  melt  the  par- 
affin. The  post-operative  effect  depends  also  largely  upon  the  amount 
of  the  material  used.  It  is  therefore  necessary  to  avoid  the  introduction 
of  any  excess,  as  undue  tension  and  destruction  of  the  skin  may  follow. 
To  avoid  this  it  is  sometimes  better  to  repeat  the  operation  if  the  need 
arises.  From  one-half  to  one  dram  or  one  and  a  half  drams  is  the 
amount  ordinarily  required.  During  the  injection  the  material  is 
molded  according  to  the  necessities  of  the  case.  A  needle-puncture 
should  be  sealed  by  a  collodion  dressing. 

Post-operative  Effects. — As  a  result  of  the  injection,  the  skin 
usually  becomes  white  and  frequently  presents  a  somewhat  swollen  and 
tense  appearance.  During  one  or  two  succeeding  days  there  may  be 
redness  and  sometimes  edema,  which  is  usually  of  a  transient  nature. 
The  application  of  iced  boric- acid  dressing  will  minimize  the  tendency  to 
painful  reaction.  No  second  injection  should  be  permitted  until  all  evi- 
dence of  any  local  irritation  resulting  from  a  previous  operation  has 


OPERATIONS.  l6l 

subsided.     The  results  of  this  method  of  correcting  external  deformities 
of  the  nose  are  very  favorable. 

Should  suppuration  occur,  an  incision  should  be  promptly  made  and 
the  parafhn  allowed  to  escape  through  the  sinus  or  opening  which  has 
formed.  The  after-treatment  is  similar  to  the  treatment  of  other  septic 
wounds. 


CHAPTER  IX. 
OPERATIONS  (Continued; 


CHAPTER  IX. 

OPERATIONS  (Continued). 

OPERATIONS    UPON    THE   NECK     (TRACHEOTOMY,    LARYN- 

GOTOMY,   ETC.). 

Technic. — ^If  the  operation  has  been  performed  for  the  removal  of 
a  foreign  body,  the  entire  wound  can  be  closed  for  primary  union.  If, 
however,  a  tracheal  tube  has  been  inserted,  it  is  imperative  that  the  pa- 
tient should  be  placed  in  a  warm  bed,  preferably  in  a  semi-erect  position, 
and  made  as  comfortable  as  possible.  The  air  must  be  kept  fresh  and  at 
a  temperature  of  about  65°  F.,  and  all  possible  draft  avoided. 

The  cannula  should  be  made  of  aluminium.  Other  metal  tubes  are 
heavy,  and  when  allowed  to  remain  in  the  trachea  for  a  few  days,  often 
excite  ulceration  by  pressure.  Every  metal  cannula  should  be  double 
and  fixed  in  position  by  means  of  silk  or  tape  passing  through  the  shield 
and  tied  around  the  neck.  When  it  is  intended  that  the  tube  shall  be 
worn  for  some  time,  it  is  better  not  to  rely  upon  a  single  or  straight  ver- 
tical incision  of  the  trachea,  but  to  exsect  a  circular  portion  of  the  anterior 
wall  equal  in  size  or  a  little  larger  than  the  required  cannula.  The  re- 
sult will  be  found  more  comfortable  to  the  patient,  and  enable  the  can- 
nula to  be  reinserted  more  easily. 

The  after-treatment  of  these  patients  must  be  conducted  with 
scrupulous  care.  The  wound  must  be  kept  perfectly  clean.  Great  care 
should  be  observed  to  keep  the  orifice  of  the  cannula  free  from  mucus 
and  the  inner  tube  clean.  A  tracheal  aspirator  for  the  removal  of  mu- 
cous membrane,  or  possibly  foreign  bodies,  from  the  air-passages  of  the 
trachea  should  always  be  at  hand.  This  does  away  with  the  filthy  and 
dangerous  practice  of  sucking  the  tube  or  cannula  when  partially  ob- 
structed. A  piece  of  dry  gauze  should  always  be  placed  over  the  tube 
to  prevent  the  entrance  of  foreign  bodies.  This  is  neatly  accomplished 
by  taking  an  ordinary  pill-box,  and  with  bottom  and  top  removed, 
stretch  a  piece  of  gauze  over  the  remaining  pasteboard  rim  and  cap  this 
over  the  orifice  of  the  tube,  holding  it  in  position  by  the  bandages  carried 
around  the  neck.     The  tube  or  cannula  should  frequently  be  cleansed 

i6s 


i66 


POSTOPERATIVE    TREATMENT. 


of  secretion.     This  should  be  done  as  rapidly  as  possible,  the  tube  being 
thoroughly  disinfected  and  oiled  before  it  is  again  introduced. 

After  the  difficulty  of  breathing  has  been  relieved  by  the  operation, 
children  usually  fall  asleep  for  several  hours  and  should  not  be  awakened. 
A  nurse  should  remain  constantly  beside  the  patient  for  a  number  of 
hours  after  operation.  The  inner  tube  should,  as  a  rule,  be  removed  and 
cleaned  every  two  hours.  Any  mucus  or  membrane  that  is  coughed  up 
should  be  wiped  away  at  once  with  a  piece  of  gauze  dipped  in  carbolic 
solution.  If  the  tracheal  aspirator  is  not  attainable  and  the  tube  becomes 
blocked  with  mucus,  a  small  feather  may  be  used  for  cleansing  purposes. 
If  the  breathing  becomes  difficult  and  the  cannula  is  clear,  a  steam  atom- 


FiG.  48. — Operation  foe.  Tracheotomy. — {Bryant.) 


izer  or  croup  kettle  with  a  solution  of  sodium  bicarbonate,  20  grains  to  an 
ounce,  will  prove  very  beneficial  to  the  patient.  Unless  the  cause  of  ob- 
struction is  a  permanent  one,  after  twenty-four  to  forty-eight  hours 
attempts  should  be  made  to  remove  the  cannula  by  temporarily  stopping 
the  tube  with  the  finger  or  a  piece  of  gauze.  The  patient  should  be  al- 
lowed to  attempt  to  breathe  through  the  mouth,  but  before  permanently 
removing  the  tube,  the  patient  should  be  gradually  accustomed  to  breath- 
ing through  the  mouth  by  plugging  of  the  cannula,  and  if  on  removing  the 
tube  asphyxia  or  spasms  occur,  the  tube  must  be  immediately  reinserted. 
If  the  tube  has  to  be  retained  for  more  than  five  or  six  days,  an  india- 
rubber  tube  should  be  substituted  for  the  metal.  A  plan  adopted  by 
Dyer  when  there  is  great  difficulty  in  getting  the  patient  to  breathe 


OPEKATKJNS.  1 67 

through  the  moiitli  is  to  intube  the  larynx  first  and  then  remove  the 
tracheal  tube.  Afler  twenty-four  to  forty-eight  hours  the  laryngeal  tube 
may  be  removed,  and  llie  trachea  closed  l)y  an  antiseptic  gau/x'  pad  and 
sterilized  adhesive  strips. 

With  regard  to  the  steam  tent,  or  "cr(;u]j  bed,"  and  the  measures  to 
be  adopted  to  keep  the  tube  clean,  I  cannot  do  better  than  quote  the 
excellent  and  practical  observations  of  Mr.  Jacobson  upon  this  head: 

"While  fully  av^^are  of  the  need  of  moisture  when  the  atmosphere  is 
dry,  when  the  membrane  tends  to  crust  and  become  fixed,  I  am  of  the 
opinion  that  the  unvarying  rule  of  cot-tenting  and  use  of  steam  is  dis- 
advantageous. The  weakly  condition  of  children  with  membranous 
laryngitis,  and  all  they  have  gone  through,  must  be  remembered.  Be- 
lieving that  such  seclusion,  and  so  little  admission  of  air,  tend  to  increase 
the  asthenia  and  any  tendency  to  sepsis,  I  much  prefer  to  be  content  to 
keep  off  drafts  by  a  screen,  which  allows  of  the  escape  of  vitiated  air 
above,  using  steam,  if  needful,  according  to  the  size  of  the  room,  fireplace, 
etc.,  and  according  to  the  kind  of  expectoration,  whether  easily  brought 
up  by  the  cough  or  feathers,  or  viscid,  quickly  drying  and  causing  whis- 
tling breathing.  If  the  temperature  can  be  otherwise  kept  up  to  60°  or 
65°,  I  much  prefer  to  use  a  thin  fiat  sponge  often  wrung  out  in  a  warm 
solution  of  boric  acid.  The  inner  tube  must  be  frequently  removed  and 
cleansed — every  hour  or  two  at  first.  If  the  secretions  dry  on  and  cling  to 
it,  they  are  best  removed  by  the  soda  solution  mentioned  below.  At 
varying  intervals  between  the  removal  of  the  tube,  any  membrane,  etc., 
which  is  blocking  it,  appearing  for  a  moment  at  its  mouth  and  then 
sucked  back,  must  be  got  rid  of  by  inserting  narrow  pheasant  feathers, 
and  twisting  them  round  before  removing  them.  If  the  exudation  is 
slight,  moist,  and  easily  brought  up  by  cough  or  feather,  sponging  or 
brushing  out  the  trachea  is  not  called  for,  but  should  be  made  use  of 
when  there  is  much  flapping,  clicking,  or  whistling  of  the  breathing;  and 
if  this  is  harsh,  dry,  or  noisy,  instead  of  moist  and  noiseless,  two  of  the 
best  solutions  are  sodium  bicarbonate,  5  to  20  grains  to  an  ounce  of  water, 
or  a  saturated  one  of  borax  with  soda.  These  may  be  applied  by  a  hand 
or  steam  spray  over  the  cannula  for  five  or  ten  minutes  at  a  time,  at  inter- 
vals varying  according  to  the  relief  which  is  given,  or  applied  with  a 
laryngeal  brush,  feather,  or  bit  of  sponge  twisted  securely  into  a  loop  of 
wire.  When  any  of  these  are  used,  the  risk  of  excoriation  and  bleeding 
and  the  fact  that  only  the  trachea  and  large  bronchi  can  be  cleansed, 
must  be  borne  in  mind ;   and  with  regard  to  manipulations  for  cleansing 


l68  POSTOPERATIVE    TREATMENT. 

the  trachea  and  removing  the  inner  tube,  it  is  most  important  to  remem- 
ber that  the  caretaking  may  be  overdone,  and  a  weakly  child  still  further 
exhausted  by  meddlesome  interference." 

Dietetics.^In  the  matter  of  nourishment,  soup,  pounded  meat, 
milk,  broth,  etc.,  should  be  given  at  first,  if  necessary  through  a  nasal  or 
esophageal  tube.  This,  however,  is  not  often  required.  Difficulty  in 
swallowing  is  liable  to  occur  on  the  third  or  fourth  day.  A  little  care  and 
encouragement  will  soon  enable  the  patient,  if  a  child,  to  overcome  this 
difficulty.  Nutrient  enemas  are  rarely  necessary  except  at  first,  in  case 
there  is  nausea  or  vomiting. 

INTUBATION. 

As  a  postoperative  measure,  intubation  may  be  employed  to  re- 
lieve dyspnea  or  as  a  curative  agent  to  effect  dilatation  in  deformity  of  the 
interior  of  the  larynx.  In  the  adult  it  is  applicable  to  a  large  variety  of 
conditions  of  laryngeal  stenosis,  both  acute  and  chronic,  among  which 
may  be  mentioned  (of  the  former)  obstruction  to  the  larynx  or  edema 
of  the  glottis  from  any  cause;  operations  upon  the  larynx;  .  incised 
wounds  or  internal  violence,  as  from  attempted  endolaryngeal  operation, 
foreign  body,  or  the  like.  The  chronic  conditions  in  which  it  is  indicated 
are  such  cases  of  postoperative  stricture  as  may  be  amenable  to  treatment 
by  the  division  of  cicatricial  bands  and  systematic  dilatation.  It  is  also 
useful  in  some  cases  of  laryngeal  neoplasm  and  in  laryngeal  paralysis 
threatening  asphyxia,  which  sometimes  follow  operations  upon  the 
throat. 

In  fractures  and  other  injuries  of  the  laryngeal  cartilages  involving 
displacement  the  presence  of  the  tube  acts  as  an  excellent  support  for 
keeping  the  displa(?ed  parts  in  proper  position,  and  from  its  unyielding 
nature  makes  possible  the  application  of  supplementary  means  for  sup- 
porting the  parts  from  the  outside. 

The  insertion  of  the  tube  is  less  difficult  in  the  adult  than  in  the 
child.  It  should  be  done,  if  possible,  with  the  aid  of  the  laryngoscopic 
mirror,  although  this  is  not  absolutely  necessary,  the  sense  of  touch  in 
one  expert  in  the  operation  being  sufficient.  The  difficulty  of  reaching 
the  larynx  with  a  forefinger  of  ordinary  length,  and  the  greater  precision 
with  which  the  tube  can  be  managed  when  seen  in  the  laryngoscope, 
make  the  latter  a  very  useful  aid.  In  passing  the  tube  the  larynx  should 
first  be  anesthetized  with  cocain.      The  patient  should  be  seated  as  for 


OPERATIONS. 


160 


the  ordinary  laryngoscopic  examination,  and  the  tube,  aided  by  the  mir- 
ror, should  be  introduced  as  in  the  infant,  except  that  the  finger  of  the 
operator  is  not  used  as  a  guide.  Instead  of  this,  as  is  customary  in  the 
passage  of  any  endolaryngeal  instrument,  the  aid  of  the  patient  is  de- 
pended upon  to  open  the  larynx  either  by  the  act  of  phonation  or  of  deep 
inspiration.     The  use  of  a  mouth-gag  in  the  adult  is  not  requirer].     In- 


FiG.  49. — O'Dwyer's  Intubation  Set. 

tubation  in  suitable  chronic  cases  has  practically  superseded  all  older 
methods  of  dilation. 

The  larynx  tolerates  the  presence  of  the  tube  with  great  readiness, 
one  of  O'Dwyer's  patients,  without  his  knowledge,  having  voluntarily 
carried  a  tube  without  removal  for  fourteen  months.  Too  long  retention 
may  injure  the  larynx,  and  is  not  recommended.  Such  a  case  should  of 
course  be  watched,  and  the  tube  removed  and  reinserted  as  often  as  re- 
quired for  cleanliness,  the  condition  of  the  parts,  or  the  necessity  for 


170 


POSTOPERATIVE    TREATMENT. 


more  active  dilatation  througli  the  insertion  of  a  tube  of  larger  diameter. 
The  instruments  used  for  the  adult  are  very  similar  to  those  for  children, 
except  that,  owing  to  the  excessive  weight  of  metal,  the  larger  sizes  may 
be  made  entirely  of  hard  rubber  or  of  the  latter  and  metal  combined. 

The  proper  time  for  removing  the  tube  from  the  larynx  will 
depend  on  the  age  of  the  patient,  the  character  of  the  disease,  whether  of 
slow  or  rapid  development,  and  the  progress  of  the  case.  In  diphtheria 
the  younger  the  patient,  as  a  rule,  the  longer  the  tube  will  be  required. 
In  children  under  two  years  of  age  it  is  better  to  leave  it  in  seven  days. 
When  the  above  disease  has  developed  slowly,  and  has  therefore  run  a 


Fig.  50. — O'Dwyer's  Intubation  Instruments. 
A.  Gold-plated  tubes.      B.  Scale.      C.  Denhart's  mouth-gag.      D.  Obturator  or  intro- 
ducer.     E.  O'Dwyer's  extractor. 


greater  part  of  its  course  before  calling  for  operative  interference,  the 
tube  can  be  dispensed  with  earlier — sometimes  so  soon  as  the  second  or 
third  day.  If  the  patient  cannot  be  seen  within  a  reasonable  time,  it  is 
safer,  if  progressing  favorably,  to  leave  the  tube  in  position  for  seven  or 
eight  days,  and  the  exceptions  are  few  in  which  it  will  be  necessary  to  re- 
insert it  after  this  time.  The  tube  should  always  be  removed  on  the  re- 
currence of  severe  dyspnea,  because  it  is  sometimes  impossible  to  ascer- 
tain with  certainty  whether  or  not  it  be  partially  obstructed.  The  best 
evidence  to  the  contrary  is  a  good  respiratory  murmur  or  numerous  rales 


OPKRATIONS. 


171 


over  the  lower  posterior  portion  of  the  lungs.  Even  iinrler  these  circum- 
stances the  lumen  of  the  tube  may  have  been  encroached  upon.  In  pa- 
tients refusing  nourishment  after  intubation  it  is  useless  to  remove  the 
tube  for  the  purpose  of  feeding,  unless  it  has  been  in  long  enough  to  give 
some  reasonable  hope  that  its  further  use  will  not  be  necessary,  as  it  is 
difficult  to  convince  children  for  some  time  that  they  can  swallow  any 
better  than  before.  If  no  dyspnea  recurs  in  half  an  hour  after  the  extrac- 
tion of  the  tube,  it  is  safe  to  leave  the  patient,  if  not  at  too  great  a  distance 
to  be  reached  within  two  or  three  hours. 

In  feeding  children  after  intubation  great  care  must  be  taken 
that  food  be  kept  out  of  the  trachea,  otherwise  a  fatal  result  is  pretty  cer- 
tain. Liquid  or  semisolid  food  may  be 
given  through  an  esophageal  tube  or  by 
enema.  The  best  method  is  to  allow 
the  child  to  swallow  it  while  his  head 

is  depressed  and  a  little  to   one  side.  nil  ^^  ^^^^-^''W^Wu 

(Dennis.) 

ESOPHAGOTOMY. 

After-treatment. — The  after-treat- 
ment of  these  cases  involves  con- 
siderable care,  and  often  not  a  few 
difficulties. 

The  patient  should  lie  in  bed,  with 
the  head  and  shoulders  well  raised. 
The  neck  must  be  fixed  and  made 
rigid,  and  this  can  be  effected  by 
means  of  one  of  the  simpler  forms  of 
apparatus  employed  in  cases  of  cervical 
caries  or  torticollis.  It  is  essential  that 
the  part  be  kept  at  rest,  and  unless  the 
head  be  fixed  it  will  be  found  that  the  re- 
gion of  the  wound  is  very  frequently  dis- 
turbed, especially  when  the  patient  is  fed. 

The  longer  the  patient  can  be  kept, 
immediately  after  the  operation,  without  food  by  the  mouth,  the  better. 
The  strength  must  be  maintained  by  nutrient  enemas.  Thirst  may  be 
relieved  by  rectal  injections  of  warm  water.  The  patient  may  be  fed  by 
a  tube  on  the  second  or  third  dav.     The  tube  should  be  soft,  and  should 


Fig.  51. — Davis  Apparatus  roR 
Torticollis  used  .-ufter  Opera- 
tion  FOR  EsOPHAGOTOMY. 

.4.  Abdominal  belt.  B.  Front  con- 
necting strap.  C.  Head  brace. 
D.  Steel  loop.  E.  Chin  strap. 
G.  Shoulder  braces  or  pads. 


172  POSTOPER.\TIVE    TREATMENT. 

be  passed  by  the  mouth.  This  method  of  feeding  must  be  repeated 
until  the  parts  are  sound.  If  the  wound  in  the  gullet  has  been  closed 
and  has  remained  closed,  the  tube  may  be  given  up  after  seven  or  ten 
days.  If  the  wound  is  left  open,  or  if  it  reopens  after  it  has  been  closed, 
the  tube  should  be  employed  until  the  wound  in  the  neck  is  granulating 
well  and  has  been  reduced  to  small  dimensions,  and  until  it  is  evident 
that  the  cut  in  the  gullet  has  healed. 

When  the  aperture  in  the  esophagus  remains  free,  there  is  a  great 
disposition  for  the  cervical  wound  to  become  very  foul,  in  spite  of  ordinary 
attention.  The  mouth  should  be  frequently  rinsed  out  with  a  carbolic 
solution,  and  the  wound,  which  should  be  dressed  very  lightly  with  gauze, 
should  be  irrigated  with  some  aseptic  solution  many  times  a  day.  When 
the  patient  is  fed  with  the  tube,  a  little  food  is  very  apt  to  escape  into  the 
mouth,  and  also  out  of  the  wound.  Both  mouth  and  wound  should, 
therefore,  be  well  washed  out  after  each  feeding.  It  is  when  milk  is  ex- 
tensively employed  that  the  parts  tend  to  become  most  foul. 

Iodoform  forms  a  very  suitable  material  for  dusting  upon  the  wound. 
The  chief  cause  of  death  in  these  cases  is  septicemia,  consequent  upon 
the  foul  condition  of  the  wound.  Other  elements  in  the  mortality  are 
cellulitis,  pneumonia,  and  exhaustion. 

OPERATIONS  UPON  THE  THYROID  GLAND,  GOITER,  ETC. 

Technic. — Before  closing  the  incision  all  hemorrhage  must  be 
completely  arrested.  The  smaller  arteries  should  be  ligated,  as  acci- 
dental or  recurrent  hemorrhage  after  these  operations  is  very  frequent, 
vomiting  being  the  most  exciting  cause,  owing  to  the  vascularity  of  the 
parts.  To  control  or  prevent  persistent  oozing  after  operation  for  goiter 
some  surgeons  now  saturate  the  entire  wound  with  a  weak  solution  of 
adrenalin  chlorid  just  before  the  final  sutures  are  placed. 

Liability  to  recurrent  hemorrhage  is  so  very  common  that  the 
patient  should  be  watched  carefully  for  several  hours  following  the  oper- 
ation. Hemorrhage  beneath  the  deep  fascia  may  so  compress  the 
trachea  as  to  cause  death  by  asphyxia.  A  sudden  onset  or  attack  of 
difficult  breathing,  accompanied  with  cyanosis,  calls  for  hurried  relief. 
The  wound  should  be  quickly  torn  open  and  issue  given  to  the  blood. 
Instead  of  sealing  these  wounds  with  collodion,  as  is  sometimes  done, 
if  a  small  piece  of  gauze  or  guttapercha  is  introduced  before  closing  the 
wound,  hemorrhage  will  be  quickly  noted  and  other  complications 
avoided.     Usually  within  twenty-four  to  thirty-six  hours  after  the  opera- 


OPERATIONS. 


173 


lion  when  no  drainage  is  used,  marked  swelling  of  the  tissue  around  the 
gland  is  often  observed;  this,  however,  rarely  calls  for  treatment  and 
gradually  disappears.  During  convalescence,  symptoms  of  thyroidism 
may  suddenly  appear,  the  most  prominent  of  which  are  tachycardia, 
tremor,  headache  and  drowsiness,  and  rapid  breathing  with  marked  ex- 
haustion. This  is  believed 
to  be  due  to  the  absorption 
of  colloid  material.  When 
this  does  occur,  the  wound 
should  be  opened  and  care- 
fully irrigated.  Rest  and 
protection  from  excitement 
are  essential  conditions 
to  successful  treatment. 
Medically,  the  treatment  is 
mainly  directed  to  the  symp- 
toms, the  remedies  mostly 
used  being  bromids  as  nerve 
sedatives,  and  digitalis  to 
slow  and  steady  the  pulse. 
Later,  nux  vomica  in  large 
doses,  as  recommended  by 
Newton,may  prove  efficient. 
Subnormal  temperature 
with  rapid  breathing,  asso- 
ciated with  cyanosis  and 
swelling  of  the  vessels  of  the 
neck,  may  call  for  adrenalin 
and  other  heart  stimulants 

with  hypodermatoclysis.     Of  68  cases  reported  by  Oppenheimer,  there 
were  9  deaths  within  twenty-four  hours. 


Fig. 


-Colloid  Goiter. — {Richardson,  ajler 
V.  Bruns.) 


ABSCESS  OF  MASTOID. 
Treatment. — After  removal  of  pus  and  all  necrosed  bone,  the 
wound  should  be  treated  after  the  open  method.  Free  drainage  is  requi- 
site. The  cavity  of  the  abscess  and  the  antrum  should  be  ver}^  gently 
packed  with  5  percent  iodoform  gauze.  This  packing  is  removed, 
when  loosened,  on  the  third  or  fourth  day.  The  antrum  and  cavity 
should  be  freely  irrigated  with  an  antiseptic  lotion  posteriorly,  and  the 


174 


POSTOPERATIVE    TREATMENT. 


fluid  allowed  to  pass  out  of  the  canal.  When  thoroughly  cleansed,  the 
cavity  and  antrum  should  again  be  packed  lightly  with  gauze.  It  will 
be  necessary  in  some  cases  to  leave  a  drainage-tube  in  situ,  especially 
when  the  abscess- cavity  is  very  foul  and  the  pus  is  fetid.  When  a  drain- 
age-tube has  been  inserted  and  there  is  a  discharge  of  pus,  the  parts 
should  be  irrigated  with  a  weak  boric-acid  solution,  and  afterward  covered 
with  iodoform  gauze  and  absorbent  cotton  and  bandaged.  Surgeons  in 
some  instances,  when  there  is  a  chance  of  healing  of  the  aseptic  wound, 
reinsert  the  disk  of  bone.  If  there  is  much  discharge,  the  dressings 
should  be  changed  each  day. 

"The  bone  which  separates  the  mastoid  cells  from  the  lateral  sinus 
is  very  thin,  so  that  when  erosion  of  the  bone  occurs,  inflammation  may 
easily  extend  to  the  lateral  sinus,  causing  thrombosis  of  the  same,  and 
emboli  may  be  thus  transmitted  to  the  cerebrum  or  cerebellum  and  form 
an  abscess,  or  abscess  may  be  developed  by  direct  inflammation  through 

the  dura  mater,  or  in  rare 
instances  by  inflammation 
extending  to  the  cerebellum 
through  the  sheath  of  the 
auditory  meatus.  Abscesses 
are  also  found  between  the 
dura  mater  and  pia  mater." 
(Dennis.) 

Complications.  —  The 
sudden  onset  of  a  rigor, 
followed  by  a  rise  of  tem- 
perature, headache,  vomit- 
ing, etc.,  indicates  menin- 
gitis. Under  such  circum- 
stances the  wound  should  be  at  once  reopened.  All  drainage  should 
be  removed  and  mild  antiseptic  lotions  used  freely.  Should  these 
means  not  suffice,  meningitis  or  abscess  may  be  expected,  and  every 
effort  should  be  made  to  locate  and  evacuate  the  pus.  It  is  to  be  remem- 
bered, however,  that  the  brain-substance,  being  poorly  supplied  with 
lymphatics,  abscess  in  its  interior  does  not,  as  a  rule,  cause  rise  of  temper- 
ature. More  frequently  in  abscess  of  the  brain-substance  the  patient's 
temperature  is  normal  or  subnormal. 

We  should  examine  carefully  with  a  probe  to  see  if  a  sinus  exists  in 
the  upper  wall.    If  not,  we  may  then  suspect  a  temporosphenoid  abscess, 


Fig.  53. — Opening  the  Mastoid  Antrum. — 
{Esmarch  and  Kowalzig.) 


OPERATIONS.  175 

and  an  incision  should  be  made  upward  above  the  zygomatic  process, 
and  with  a  trephine  remove  a  disk  of  Ijone  3  cm.  in  diameter  at  a  point 
(see  Fig.  53)  of  the  external  auditory  canal  from  2.5  to  3  cm.  above  the 
external  meatus.  In  abscesses  in  the  brain  due  to  middle-ear  disease 
Keen  trephines  at  "Barker's  point" — 1|  inches  above  and  i\  inches  back 
of  the  extreme  auditory  meatus.  Horsley  also  follows  this  rule. 
After  removing  the  disk  of  bone,  if  the  abscess  is  large,  there  will  probabl}' 
be  some  bulging  of  the  dura  mater  into  the  opening.  There  may  or  may 
not  be  absence  of  cerebral  pulsation.  The  dura  should  be  divided  and 
the  arachnoid  and  pia  mater  examined.  By  means  of  a  hypodermatic 
syringe  and  needle  the  different  portions  of  the  brain  can  be  explored  for 
abscess.  The  needle  should  be  introduced  so  as  to  cover  the  cranial 
surface  of  the  tegmen  tympani.  After  the  pus  has  been  evacuated  the 
abscess-cavity  should  be  washed  out  with  a  very  weak  boric-acid  solution 
and  but  very  little  pressure  used;  otherwise  the  brain-substance  may  be 
injured. 

EMPYEMA  OR  PLEUROTOMY. 

Postoperative  Treatment. —  When  a  permanent  treatment  is  to 
be  provided,  the  opening  should  be  made  at  the  lowest  part  of  the  cav- 
ity— in  the  mammary  line,  by  removing  the  cartilage  of  the  sixth  rib;  in 
the  lateral  region,  the  right  pleura  may  be  opened  by  removing  the  ninth 
rib;  and  the  left,  by  removing  the  tenth  rib;  posteriorly  in  the  scapular 
line  on  either  side,  by  removing  the  twelfth  rib,  the  presence  of  fluid  being 
previously  ascertained  by  puncture  or  aspiration.  After  a  free  opening 
has  been  made,  a  probe  or  the  finger  is  introduced  to  ascertain  the  deeper 
part  of  the  cavity,  over  which  a  second  opening  may  be  made  by  resection 
of  a  portion  of  the  rib.  In  this  way  provision  is  made  for  syringing  the 
pleural  cavity  through  the  two  openings.     (Kocher.) 

Schede  has  demonstrated  that  expansion  of  the  lung  takes  place  best 
when  the  thorax  is  opened  at  the  deepest  and  most  posterior  part.  Bv 
following  Schede's  procedure,  the  cavity  may  be  at  once  Avashed  out,  a 
short  T-shaped  drainage-tube  being  used  to  permit  the  free  escape  of 
fluid.  Repeated  washing  out  of  the  cavity  should  be  avoided,  as,  accord- 
ing to  Schede,  it  interferes  greatly  with  the  adhesions  of  the  pleura.  Fetid 
empyemas,  however,  should  be  washed  out,  and  retention  of  pus  must  be 
prevented  by  ef&cient  drainage.  In  purulent  pleural  exudation  thorough 
and  early  evacuation  is  the  best  procedure.  Complete  mobility  and  ex- 
pansion of  the  lung  is  best  obtained  by  early  and  thorough  operation. 


176  POSTOPERATIVE    TREATMENT. 

The  dressings  becoming  soiled  permit  the  air  to  escape  from  the  cavity 
upon  forced  expiration,  but  by  compressing  the  drainage-tube  or  opening 
the  ingress  of  a<ir  may  be  impeded. 

Hutton  seeks  by  means  of  a  very  ingeniously  contrived  mechanical 
device  to  permit  thorough  drainage,  and  upon  forced  expiration,  the  escape 
of  air;  but  by  the  action  of  the  valve  in  the  device  the  air  is  prevented 
from  entering  the  cavity,  and  thus  secures  the  operation  of  atmospheric 
pressure,  preventing  collapse  of  the  chest  walls. 

Delorme  has  lately  suggested  a  method  for  bringing  about  the  closure 
of  old  empyema  cavities,  which,  when  available,  gives  a  better  result  than 
ordinary  methods.  After  opening  the  pleura  he  separates  extensively  the 
adhesions  to  the  lung  and  then  performs  a  decortication  of  the  cicatrized 
tissue  from  the  surface  of  the  lung,  thus  enabling  the  lung  to  expand 
sufhciently  to  come  in  contact  with  the  inner  wall  of  the  chest.  If  on 
dividing  the  pleural  adhesions  it  is  found  that  the  lung  is  still  capable  of 
expansion,  and  that  the  adhesions  can  be  peeled  off,  nothing  further  is 
required,  providing  the  lung  expands  sufficiently  to  fill  up  the  cavity;  but 
if  the  lung  does  not  expand  sufficiently,  Depage's  operation  should  be 
resorted  to,  and  one  or  more  ribs  resected  from  the  pleural  surfaces  of  the 
raised  flap,  commencing  with  the  lowest  one. 

Christie,  Jr.,  reports  a  most  gratifying  result  from  the  following 
method:  The  case  is  treated  as  a  simple  drainage  case — that  is,  with  re- 
section of  one  rib  and  drainage  through  a  tube  for  three  weeks.  At  this 
time  union  and  moderately  firm  cicatrization  of  the  cutaneous  and  sub- 
cutaneous incision  will  have  been  secured,  and  there  will  remain  a  simple 
sinus  leading  into  the  pleural  cavity.  By  means  of  a  simple  apparatus 
which  is  attached  to  the  vacuum  chamber  of  an  ordinary  aspirator 
he  forcibly  extracts  all  the  air  from  the  pleural  cavity  and  at  once  secures 
the  effect  of  full  atmospheric  pressure  within  the  lung  and  against  the 
thoracic  wall, .which  forcibly  induces  the  immediate  expansion  of  the 
lung,  after  which  the  wound  is  effectually  plugged  by  means  of  a  water- 
cushion  and  rubber  dam  eight  inches  wide;  the  purpose  of  the  dam 
being  to  form  an  impervious  contact  with  the  chest  walls. 

Should  irrigation  of  the  pleural  cavity  at  any  time  be  considered 
desirable,  normal  salt  solution  or  weak  iodin  solution  only  should  be 
used.  The  drainage-tube  must  be  continued  until  all  discharges  have 
ceased  entirely.  The  patients,  who  are,  as  a  rule,  very  much  emaciated, 
should  be  placed  upon  tonics  with  forced  nutrition. 

Senn's  Method  of  Drainage  and  After-treatment. — Tubular  drain- 


OPERATIONS. 


177 


age  is  the  ideal  method  of  draining  a  supj^urating  pleural  cavity.  Two 
fenestrated  tubular  drains  the  size  of  the  little  finger  and  about  four  inches 
in  length,  securely  fastened  together  with  a*  large  safety-pin  or  a  stitch 
through  each  end,  should  be  used  for  this  purpose.  This  precaution  is 
absolutely  necessary,  as  drains  have  been  frec|uently  iost  in  the  pleural 
cavity  for  want  of  securing  with  a  large  safety-pin.  After  inserting  the 
tubular  drain,  the  external  wound  is  sutured  in  the  usual  manner.  The 
curved  incision,  as  previously  described,  not  only  exposes  the  rib  more 
freely  than  the  straight  incision  as  usually  practised,  but  also  is  much 
better  adapted  for  efficient  prolonged  drainage. 


Fig.  54. — External  Wound  Partly  Sutured;  Double  Drain  in  Place. — {Senn.) 

It  is  not  advisable  to  irrigate  the  cavity  the  day  the  operation  is 
performed,  and  irrigation  at  this  time  is  always  contraindicated  if  the 
empyemic  cavity  is  in  communication  with  the  bronchial  tubes.  Irri- 
gation may  become  necessary  later  if  the  suppuration  continues.  If 
irrigation  becomes  necessary  at  any  time,  care  must  be  exercised  in  the 
selection  of  the  solution;  carbolic  acid  and  corrosive  sublimate  in  the 
usual  strength  are  dangerous  and  should  never  be  used.  A  nontoxic 
and  yet  potent  antiseptic  solution  should  be  used — either  a  saturated 
solution  of  aluminium  acetate  or  Thiersch's  solution.  Either  of  these 
solutions  is  efficient  as  an  antiseptic,  and  nontoxic  even  when  used  in 
large  quantities.  The  value  of  the  double  drain  is  made  more  appar- 
ent when  it  becomes  necessary  to  irrigate  the  pleural  cavity.  By  plac- 
ing the  patient  on  the  opposite  side  the  fluid  that  enters  the  chest  through 
13 


178 


POSTOPERATIVE    TREATMENT. 


one  of  the  tubes  escapes  through  the  other  as  soon  as  the  cavity  is  full, 
thus  washing  it  out  thoroughly.  By  placing  the  patient  on  the  affected 
side  the  cavity  is  emptied,  when  the  same  procedure  is  repeated  until 
the  solution  returns  clear.  The  solution  used  must  always  be  heated 
to  blood-temperature,  as  irrigation  with  a  cold  solution  is  fraught  with 
danger.  I  have  seen,  in  the  case  of  a  child,  almost  fatal  collapse  attend 
irrigation  of  the  pleural  cavity  with  a  solution  at  room-temperature. 
It  required  persistent  and  prolonged  efforts  to  restore  the  suspended 

respiration  by  the 
administration  of 
stimulants  and  arti- 
ficial  respiration. 
The  external  dress- 
ing consists  of  a 
large  and  thick 
cushion  of  sterile 
gauze  and  cotton 
to  absorb  the  fluid 
as  fast  as  it  escapes, 
and  at  the  same 
time  to  provide  the 
wound  with  a  filter 
to  prevent  postoper- 
ative infection. 
There  is  no  special 
advantage  in  using 
medicated  in  place 
of  sterile  absorbent 
material,  so  long  as 
the  compress  is  re- 
moved, as  it  should 
be,  as  soon  as  in- 
dications of  satura- 
tion appear  on  its 
surface.  The  best  way  to  retain  the  dressing  in  place  and  to  prevent  the 
entrance  into  the  pleura  of  unfiltered  air  is  to  substitute  for  the  ordinary 
bandage  the  rubber- webbing  bandage,  or  to  place  over  the  gauze  roller, 
over  the  upper  and  lower  margin  of  the  dressing,  a  band  of  the  rubber- 
webbing  bandage.     Change  of  dressing  and  antiseptic  irrigation  become 


Fig.  55. — Dressing  after  Operation  for  Empyema.- 
(Senn.) 


OPERATIONS. 


179 


necessary  as  often  as  the  dressing  becomes  saturated.  For  the  purpose  of 
obviating  frequent  changes  the  dressing  should  be  at  least  six  inches  thick 
and  cover  the  whole  side  of  the  chest.  As  the  cavity  diminishes  in  size  the 
drains  are  shortened  from  time  to  time,  and  sooner  or  later  one  of  them 
can  be  dispensed  with.  Premature  removal  of  the  drain  is  often  followed 
by  relapse;  drainage  must  not  be  suspended  until  the  surgeon  can  satisfy 
himself  by  careful  examination  that  the  pleural  cavity  has  become  oblit- 
erated. Should  the  lung  fail  to  expand  sufficiently  in  the  course  of  a  few 
months  to  place  the  cavity  in  a  condition  for  definitive  healing,  Schede's 
thoracoplasty  is  the  operation  of  choice,  as  Estlander's  multiple  rib 
resection  has  not  yielded  the  expected  results  in  the  practice  of  many 
operators,  including  myself. 

It  is  well  for  the  surgeon  to  keep  close  watch  on  the  size  of  the  empy- 
emic  cavity  during  the  after-treatment,  not  only  for  the  purpose  of  keep- 
ing himself  well  informed  of  the  progress  of  the  healing  process,  but  also 
with  a  view  to  determining  the  time  when  it  is  safe  to  abandon  drainage. 
For  a  long  time  it  has  been  my  custom  to  place  my  patient,  at  stated 
intervals,  on  the  opposite  side,  then  to  fill  the  cavity  with  one  of  the  anti- 
septic solutions  used  for  irrigation,  then  evacuate  the  chest  by  reversing 
the  position,  and  measure  the  quantity  of  fluid  removed.  This  procedure 
can  be  relied  upon  in  giving  the  size  of  the  cavity,  and  should  be  em- 
ployed systematically  at  fixed  intervals,  to  ascertain  the  proper  time  for 
the  removal  of  the  drain. 

AMPUTATION  OR  EXCISION  OF  THE  BREAST. 

Technic. — The  operation,  although  extensive,  is  usually  performed 
with  little  loss  of  blood,  and  therefore  with  little  shock.  The  wound 
should  be  closed  by  bringing  together  the  flaps  so  that  the  axilla  at 
least  is  completely  closed.  A  single  drainage-tube  should  be  inserted 
well  below  the  lowest  part  of  the  incision  and  extend  upward  between 
the  chest  wall  and  muscular  tissues  as  far  as  the  clavicle.  Any  part  of 
the  wound  which  cannot  be  closed  should  be  at  once  grafted  by 
Thiersch's  method. 

"The  functional  disturbances  which  follow  such  an  extensive  opera- 
tion and  removal  of  muscle  are  not  so  severe  as  one  would  expect,  be- 
cause the  anterior  fibers  of  the  deltoid  are  able  to  pull  the  arm  forward, 
and  the  latissimus  dorsi  to  adduct  it.  The  complete  removal  of  glands 
is  a  more  important  matter,  and  the  obstruction  to  the  flow,  of  lymph, 


i8o 


POSTOPERATIVE    TREATMENT. 


especially  if  the  main  vein  has  been  ligated,  is  a  more  serious  complica- 
tion. In  this  case  a  solid  edema  develops,  with  elephantiasis  of  the  arm, 
which  may  last  for  months  or  years,  and  which  interferes  much  more  with 
the  function  of  the  arm  than  does  removal  of  the  muscle." — (Kocher.) 

After-treatment. — A  matter  of  considerable  importance,  so  often 
overlooked  in  the  after-treatment  for  excision  of  the  breast,  is  the  position 
of  the  arm  during  convalescence.  Many  surgeons  teach  or  insist  upon 
immobility,  fixing  the  arm  either  by  adhesive  plasters  or  bandages  imme- 
diately after  the  operation.     This  is  not  good  practice. 

Triangular  Dressing  of 
Arm  after  Excision  of 
Breast. — J.  A.  Bodine  has  de- 
vised a  method  of  dressing  the 
arm  during  healing  after  breast 
amputations.  (Fig.  58,  page 
182.)  He  uses  a  triangular 
splint  which  places  the  arm  at 
a  right  angle  to  the  body.  He 
calls  attention  to  the  conse- 
quent freedom  with  which  the 
patients  can  use  their  arms. 
He  has  been  using  this  dressing 
in  all  such  cases  for  the  past 
few  years.  An  isosceles  tri- 
angle, made  of  light  splint 
wood,  held  in  position  by 
rubber  adhesive  strips,  is  so 
placed  against  the  side  of  the 
chest  that  the  upper  arm  is  at 
a  right  angle  to  the  body,  while 
the  forearm  in  supination  rests 
along  one  side  of  the  triangle  with  the  hand  resting  upon  the  hip. 
The  triangle  presses  along  the  body  between  the  line  of  incision  for 
removal  of  the  breast  and  the  posterior  puncture  made  for  the  drainage- 
tube.  The  arm  being  in  this  position,  the  patient  is  perfectly  comfort- 
able while  in  bed  and  also  while  walking  about.  Adherence  of  the  skin 
flap  and  scar  to  the  under  surface  of  the  arm  after  enucleation  of  the 
axillary  contents  is  an  inch  and  a  half  to  two  inches  nearer  the  shoulder 
than  it  is  when  bound  against  the  chest.     It  is  this  difference  in  position 


Fig.  56. — Illustrates  the  Customary 
Method  of  Bandaging  or  Dressing 
THE  Arm  after  Excision  of  the  Breast. 


OPERATIONS. 


I»I 


of  attachment  of  the  scar  and  skin  flap  to  the  arm  that  gives  such  freedom 
from  cicatricial  contraction  following  amputation  of  the  breast. 

Dawbarn  has  several  times  employed  the  method  demonstrated  by 
Bodine.  It  is  more  comfortable  because  the  a]jdu(:tif)n  of  the  arm  slides 
the  scar  so  that  it  does  not  adhere  to  the  region  of  the  vein  nor  the  main 
lymphatics.  Patients  at  times  have  been  made  very  miserable  after  am- 
putation of  the  breast  by  swelling  of  the  arm,  due  to  adhesion  of  the  scar, 
the  forearm  and  arm  becoming  large  and  erlematous  and  annoying  the 
patient  for  a  long  time.  This 
may  be  avoided  by  carrying 
the  incision  up  the  middle  of 
or  even  posterior  part  of  the 
axilla,  although  the  main  dis- 
section is  sharply  forward  in 
the  anterior  portion  of  the 
axilla  where  the  main  vessels 
lie.  In  commenting  upon  this 
method  of  dressing  Dawbarn 
("Albany  Medical  Journal") 
writes:  "There  is  only  one 
muscle  which  can  take  the 
place  of  the  pectoralis  major 
and  minor,  both  of  which  must 
be  entirely  removed  in  the  mod- 
ern operation,  and  that  is  the 
deltoid.  It  is  wonderful  how 
this  muscle,  hypertrophied, 
and  being  inserted  into  the 
outer  third  of  the  collar-bone, 
with    a    very    poor   leverage, 

accomplishes  its  mission."  In  the  case  of  women  who  have  very  weak 
deltoids,  it  has  been  part  of  his  regular  operation  of  late  years  to  dissect 
free  from  the  clavicle  one  inch  of  the  anterior  edge  of  the  deltoid,  and  to 
carry  it  inward  so  far  as  it  will  easily  go,  and  then  to  sew  it  to  the  stump 
of  the  pectoralis  major.  That  muscle,  in  course  of  time,  becomes  h}^er- 
trophied,  and  it  helps  a  great  deal;  but  in  cases  in  which  this  operation  is 
performed  it  obviously  would  not  do  to  use  the  isosceles  triangle,  "«dth  its 
necessary  abduction  of  the  arm.  In  the  technic  just  described,  as  to  the 
deltoid,  the  cephalic  vein  is  liable  to  cause  trouble,  and  he  generally  ties 


Fig.  57. — Shows  the  Ordinary  Result  with 
Contracted  Scar  and  Liiiited  Motion 
OF  Arm. 


l82 


POSTOPERATIVE    TREATMENT. 


it  off,  but  this  may  not  be  necessary  if  great  care  is  taken.  It  is  only 
when  the  axillary  vein  is  involved  in  the  cancerous  growth  that  saving 
the  little  cephalic  vein  becomes  a  matter  of  importance. 


Fig.  58. — Bodine's  Method  of  Dressing  after  Breast  Amputations,  also 
Showing  Angular  Splint. 


For  several  years  we  have  abandoned  the  customary  or  fixed  method 
of  dressing  as  wholly  unnecessary,  if  not  harmful.  The  arm  should  be 
practically  free,  and  the  patient  allowed  to  move  it  gently  as  early  as 
possible.  The  results  are  often  surprising:  pain  ceases  much  sooner, 
and  a  free  and  movable  arm  is  the  outcome.  Fig.  59  illustrates  the 
author's  method  of  bandaging  with  the  arm  free.  A  wedge-shaped  pad 
of  absorbent  cotton  holds  the  arm  outward  and  prevents  contact  with  the 


OPKRATIONS. 


183 


Fig.  59. — Author's  Method  or  Dressing  after  Amputation  of  Right   Breast. 

Arm  Free  and  Movable. 


Fig.  60. — Same,  Showing  Mobility  of  Arm  Twenty-one  Days  after  Amputation 

of  Breast. 


184  POSTOPERATIVE    TREATMENT. 

breast.     Fig.  60  illustrates  freedom  of  motion  a  few  weeks  following  the 
operation. 

The  after-treatment  is  practically  the  same  as  after  other  operations 
or  large  wounds.  All  saturated  dressings  should  be  removed  as  early  as 
possible,  and  fresh  ones  applied  over  the  wound  after  twenty- four  hours. 
The  drainage-tube  should  be  shortened  at  the  daily  dressings  until  all 
discharge  ceases.  The  stitches  require  removal  in  from  nine  to  fourteen 
days,  support  being  given  with  sterile  adhesive  straps. 


CHAPTER  X. 

OPERATIONS  ON  THE  STOMACH,  LIVER,  AND 

INTESTINES. 


CHAPTER  X. 
OPERATIONS  ON  THE  STOMACH,  LIVER,  AND  INTESTINES. 

OPERATIONS  UPON  THE  STOMACH. 

General  Remarks. — In  gastroenterostomy  and  other  operations 
upon  the  stomach  fauhy  technic  or  failure  to  select  a  proper  site  for  the 
anastomosis  not  only  retards  recovery,  but  often  complicates  seriously  the 
postoperative  treatment  of  these  cases.  Patients  requiring  such  surgical 
interference  are  very  frequently  markedly  emaciated,  and  the  stomach, 
as  a  result  of  the  decomposed  food  and  retained  contents,  very  frequently 
becomes  elongated  or  distended  to  such  a  degree  as  to  cause  a  deformity 
in  its  outlines.  This  element  of  deformity  is  an  important  factor  in  the 
explanation  of  the  unsatisfactory  conditions  which  persist  after  many  of 
these  operations,  and  must  not  be  overlooked.     (Ochsner.) 

In  order  to  secure  proper  drainage  of  the  stomach  it  is  essential  that 
the  lowest  possible  place  in  the  stomach  should  be  chosen.  The  selec- 
tion also  of  a  proper  point  in  the  small  intestines,  not  too  close  to  the 
pylorus,  and,  lastly,  the  avoidance  of  tension  of  both  gut  and  stomach,  are 
likewise  of  the  greatest  importance.  (Mayo.)  Good  and  sufficient 
drainage  is  manifest  by  immediate  improvement  in  the  patient's  nutrition 
and  general  condition.  When  there  is  evidence  of  retention  of  blood  or 
mucus  within  the  stomach  immediately  following  the  operation,  the 
pharynx  should  be  cocainized  to  prevent  retching  and  vomiting,  a 
stomach- tube  inserted,  and  gastric  lavage  with  normal  salt  solution  gently 
given,  in  order  not  to  overdistend  the  stomach.  It  is  often  surprising  to 
find  how  much  fluid  will  collect  in  the  stomach  after  this  operation. 
(Ochsner.)  It  is  my  experience  that  the  use  of  the  Murphy  button  in 
gastroenterostomy  is  attended  by  more  discomfort  or  pain  to  the  patient 
than  the  ordinary  suture  method,  the  mechanical  weight  of  the  button 
causing  an  unpleasant  feeling  or  dragging  sensation;  and  it  sometimes 
happens  in  greatly  reduced  patients  that  a  sudden  jar  or  jolt,  such  as  a 
paroxysm  of  coughing,  sneezing,  or  vomiting,  may  cause  a  loosening  of 
the  button  or  drag  it  from  its  position  in  the  stomach,  \\rhen  the  Murphy 
button  is  employed  in  gastroenterostomy,  it  is  therefore  advisable  to  rein- 

187 


ISO  POSTOPERATIVE    TREATMENT. 

force  the  place  of  anastomosis  by  employing  the  adjacent  omentum  as  a 
covering,  as  recommended  by  Nicholas  Senn  and  others. 

Postoperative  Treatment. — The  patient  should  not  lie  flat  on 
the  back  in  bed-  after  stomach  operations,  especially  after  gastroenter- 
ostomy, since  the  escape  of  stomach  contents  into  the  intestine  is  facili- 
tated by  the  patient  being  slightly  propped  up.  In  some  cases,  too, 
turning  on  the  right  side  also  facilitates  the  outflow  of  stomach  contents. 
It  is  unnecessary  to  state  that  the  patient  must  not  move  himself,  but 
must  allow  the  nurses  to  change  his  position.  This  change  of  position 
also  has  an  influence  on  the  bowels,  since  it  often  relieves  gaseous  or  fecal 
accumulation. 

Lavage. — If  vomiting  and  eructation  continue  after  the  second  day, 
and  especially  if  at  the  same  time  the  temperature  is  elevated,  the  mouth 
dry,  and  the  tongue  sticky  and  coated,  it  is  almost  certain  that, there 
is  some  decomposition  of  stomach  contents.  If  these  contents  are  allowed 
to  remain  in  the  stomach,  they  will  probably  produce  a  fatal  issue,  either 
by  setting  up  diarrhea,  by  keeping  up  vomiting,  or  by  absorption  of 
toxins.  It  is  very  important  that  they  should  be  removed  at  once;  to  do 
this,  a  stomach-tube  must  be  passed,  and  the  stomach  thoroughly  washed 
out  with  some  antiseptic,  such  as  salicylic  acid,  followed  by  plain  boiled 
water,  which  must  be  continued  until  the  fluid  returned  is  quite  clear. 
Feeding  must  be  recommenced  immediately  after  the  lavage,  as  this  will 
be  a  favorable  time  for  the  absorption  of  nourishment.  The  lavage 
must  be  repeated  on  th^  next  day  if  vomiting  or  eructation  continues.  In 
some  cases  it  may  require  to  be  done  daily  for  five  or  six  days. 

Some  hesitation  might  be  felt  at  passing  a  stomach-tube  forty-eight 
hours  after  suture  of  the  stomach,  and  injecting  water  to  wash  out  its 
contents,  since  this  might  place  a  strain  on  the  stitches;  however,  it  is  far 
better  that  a  suture  should  undergo  a  slight  strain  than  that  it  should  be 
soaked  in  a  putrid  liquid;  besides,  the  wound  in  the  stomach  is  firmly 
sealed  at  the  end  of  forty-eight  hours,  and  it  will  probably  resist  any  pres- 
sure that  is  likely  to  be  exerted  in  gastric  lavage.  The  lavage,  of  course, 
must  be  done  gently,  the  patient  lying  on  his  back,  and  the  fluid  intro- 
duced by  means  of  a  funnel  which  must  not  be  more  than  three  feet  above 
the  patient's  head;  it  is  removed  by  siphon  action,  not  by  expression. 

Laxatives. — A  goodly  number  of  cases  of  operations  on  the  stomach 
never  require  any  aperient,  and  the  bowels  act  naturally  on  the  second 
or  third  day;  in  some  instances  the  other  extreme  is  reached,  or  a 
troublesome    diarrhea   may   follow   which    may   cause    a   fatal   issue 


OPERATIONS    ON    STOMACH,    LIVER,    AND    INTESTINES.  1 89 

without  leaving  any  signs  at  necropsy.  In  all  cases  of  diarrhea  the 
amount  of  liquids  given  should  be  diminished,  anrl  linclurc  oi  opium 
must  be  administered  ])y  the  mouth,  and  the  stomach  washed  out;  this 
will  usually  stop  the  diarrhea. 

Rectal  Feeding. — Rectal  feeding  in  all  operations  ujjon  the  stomach 
is  requisite  for  several  days,  and  some  account  of  the  best  form  of  carry- 
ing this  out  will  be  useful. 

In  the  first  place,  before  commencing  nutrient  enemas  it  is  best  to 
wash  out  the  bowel  thoroughly  with  normal  saline  solution ;  this  must  be 
repeated  each  day  to  remove  the  debris.  The  patient  should  be  lying  on 
his  back,  and  should  not  change  his  position  for  some  time  after  the  in- 
jection. The  best  method  of  introduction  is  to  use  a  soft-rubber  rectal 
tube  the  size  of  a  No.  12  or  No.  14  catheter,  which  should  be  passed 
about  six  inches  up  the  rectum;  connected  with  the  tube  is  a  funnel 
which  should  be  raised  two  feet  above  the  bed.  This  is  better  than  a 
Syringe,  since  the  fluid  will  flow  more  evenly  and  slowly  into  the  rectum, 
and  so  is  more  likely  to  be  retained;  the  risk  of  forcing  in  air,  too,  is 
diminished.  The  whole  enema  should  not  exceed  six  ounces  in  bulk, 
and  in  some  irritable  rectums  only  three  or  four  ounces  should  be  given ; 
it  should  be  of  a  temperature  of  100°  F.,  and  should  be  given  every  four 
or  six  hours.  Practically  only  substances  in  solution  can  be  absorbed 
from  the  rectum,  so  unpeptonized  milk  or  beef-tea  is  useless;  stimu- 
lants, such  as  spirits,  wine,  tea,  or  coffee,  are  most  readily  absorbed,  but 
extractives  and  peptones  are  also  of  value.  The  necessity  of  giving 
digested  meat  has  been  recognized  for  a  long  time,  but  the  process  of  pre- 
paring the  enemas  has  been  much  improved  by  the  introduction  of  the 
various  peptonizing  or  digestive  powders  now  on  the  market.  The 
older  enemas  were  prepared  with  fresh  pancreas.  The  following  are  a 
few  of  the  best : 

1.  Von  Leube's:  Five  ounces  of  finely  scraped  meat  is  chopped 
very  fine,  and  to  this  is  added  one  and  a  half  ounces  of  finely  chopped 
pancreas ;  the  whole  is  suspended  in  three  ounces  of  lukewarm 
water,  and  stirred  to  the  consistence  of  a  thick  pulp.  This  makes  one 
injection. 

2.  Mayet's:  150  to  200  grams  of  pancreas  is  bruised  in  a  mortar  with 
tepid  water  at  a  temperature  of  100°  F.,  and  is  then  strained  through  a 
cloth;  400  to  500  grams' of  lean  meat  is  chopped  fine,  and  the  strained 
pancreatic  fluid  is  mixed  with  the  mince,  together  with  the  yolk  of  one 
egg.     This  is  allowed  to  stand  for  two  hours,  and  administered  at  the 


IQO  POSTOPERATIVE    TREATMENT. 

body-temperature ;  the  quantity  is  sufficient  for  twenty-four  hours'  nour- 
ishment, and  should  be  administered  in  two  parts. 

3.  Rennie's:  Half  a  pound  of  lean  meat  is  pulled  into  shreds  and 
added  to  a  pint  of  beef-tea;  to  this  are  added  one  dram  of  fresh  pepsin  and 
half  a  dram  of  dilute  hydrochloric  acid;  the  mixture  is  kept  at  at  empera- 
ture  of  99°  F.  for  four  hours,  during  which  it  is  stirred  constantly.  If  too 
great  heat  is  employed,  the  digestion  will  stop. 

4.  The  enema  which  the  author  employs  is  made  as  follows :  Milk  2 
ounces,  strong  beef-tea  2  ounces,  yolk  of  egg  i,  pancreatic  solution  i 
dram.  This  is  to  be  prepared  one  hour  before  use,  and  to  be  kept  at  a 
temperature  of  100°  F.  One-half  to  one  ounce  of  brandy  is  added,  when 
necessary,  immediately  before  use. 

5.  Terrier  and  Hartman  recommended  the  following:  Peptones  20 
grams,  infusion  of  tea  100  grams,  benzonaphthol  |  centigram,  tincture 
opium  5  minims.     Four  of  these  are  given  during  the  twenty- four  hours. 

6.  Greig  Smith's :  One  egg  is  beaten  up  in  six  ounces  of  milk,  and  two 
or  three  teaspoonfuls  of  meat  jelly  or  peptones  added.  This  is  adminis- 
tered warm  with  or  without  half  an  ounce  of  brandy  every  five  or  six 
hours. 

7.  Hunter  Robb's:  Peptonized  milk  i  ounce,  whisky  |  ounce,  the 
whites  of  2  eggs,  common  table-salt  14  grains. 

Nutrient  suppositories  are  also  used  when  the  rectum  is  intolerant  of 
injections,  or  they  may  advantageously  be  used  alternately  with  them  in 
cases  requiring  several  days'  rectal  feeding.  If  used  alone,  they  must  be 
supplemented  by  an  injection  of  about  half  a  pint  of  hot  saline  solution 
once  or  twice  a  day.  The  suppositories  are  usually  made  of  peptonized 
beef,  a  chocolate-colored  paste  which  is  prepared  by  digesting  beef  with 
acidified  fresh  gastric  juice,  and  then  concentrating  the  solution.  The 
suppository  contains  30  grains  of  this,  and  is  stiffened  with  cacao-butter. 
These  suppositories  are  made  by  most  wholesale  chemists,  and  keep  only 
for  a  short  time  after  the  box  is  opened.  It  is  best  to  use  them  freshly 
prepared. 

Lastly,  Sansom  has  recommended  the  use  of  blood  as  an  enema.  Ox 
blood  is  usually  employed,  and  must  be  defibrinated  first;  this  can  be 
obtained  from  a  butcher  by  asking  for  whipped  blood.  It  must  be  fresh, 
and  will  not  keep  more  than  one  day.  By  the  addition  of  one  and  a  half 
grains  of  chloral  to  one  ounce  of  blood  all  offensive  odor  is  overcome. 
It  is  usual  to  inject  two  or  three  ounces  of  blood  every  two  or  three  hours. 

In  case  rectal  feeding  has  to  be  continued  for  any  length  of  time  it  is 


OPERATIONS   ON   STOMACH,    LIVER,   AND    INTESTINES.  191 

well  to  change  the  composition  of  the  enema,  since  the  rectum  does 
not  appear  to  retain  any  one  kind  of  enema  long.  If,  too,  the  rectum  be 
irritable,  two  or  three  minims  of  tinctura  opii  should  be  added  to  each 
enema.  Some  surgeons  also  add  some  disinfectant  to  each  enema,  either 
betanaphthol  or  salol ;  from  2  to  5  grains  of  each  can  be  given.  Alcohol 
also  acts  as  a  disinfectant,  as  well  as  a  stimulant,  so  this  is  an  additional 
reason  for  adding  either  brandy  or  red  wine,  as  suggested  by  Ewald. 
(See  also  article  on  Rectal  Alimentation.) 

CHOLECYSTOTOMY. 
General  Considerations. — Operations  upon  the  gallbladder  should 
be  deferred,  if  possible,  until  all  symptoms  of  acute  inflammation  have 
entirely  subsided.  When  catarrh  or  inflammation  coexists,  simple  chole- 
cystotomy  should  not  be  performed.  A  relatively  small  incision  in  the 
abdomen  is  usually  all  that  is  required.  If  the  walls  of  the  gallbladder 
are  found  to  be  normal  so  that  the  indication  is  merely  to  remove  the 
contents,  especially  gallstones,  the  gallbladder  is  drawn  into  the  wound 
and  fixed  there  firmly  by  means  of  forceps.  Sterile  gauze  tampons  are 
now  carefully  inserted  well  around  the  gallbladder  to  prevent  infection 
and  entrance  of  bile  into  the  peritoneum.  The  fundus  may  now  be  in- 
cised, the  fluid  contents  evacuated,  and  the  calculi  removed  by  means  of 
a  scoop  and  forceps.  After  the  extraction  of  the  stones  the  wound  in  the 
gallbladder  is  closed  by  a  double  row  of  sutures,  as  in  suture  of  intestines. 
The  gallbladder  is  then  replaced,  all  gauze  packing  removed,  and  the 
wound  is  carefully  closed  by  deep  sutures  and  sealed.  Many  surgeons, 
however,  prefer  to  treat  the  wound  after  the  open  method — i.  e.,  a  strip  of 
iodoform  gauze  is  introduced  down  to  the  sutured  gallbladder  and 
allowed  to  remain  three  or  four  days,  after  which  it  is  removed,  and  if 
there  is  no  indication  of  infection  or  leakage  from  the  gallbladder,  the 
wound  is  closed  or  drawn  together  with  adhesive  plaster.  When  gall- 
stones have  become  impacted  in  the  ductus  choledochus,  the  surgeon  is 
confronted  with  a  new  set  of  indications  for  treatment .  The  prognosis  is 
then  more  unfavorable,  because  the  patient  is  the  subject  of  jaundice, 
and  an  old-standing  icterus  produces  an  exceedingly  dangerous  hemor- 
rhagic diathesis.  A  larger  incision  is  usually  required.  The  gaUbladder 
is  exposed.  Iodoform  gauze  is  gently  but  thoroughly  packed  around 
the  gallbladder,  and  especially  the  lower  portion,  to  prevent,  as  before, 
any  possible  infection  of  the  peritoneum.  The  gallbladder  is  drawTi 
well  into  the  wound  and  stitched  carefully  with  four  to  six  sutures  to  the 


192  POSTOPERATIVE    TREATMENT. 

subcutaneous  tissues,  but  not  to  the  skin.  Block  and  other  surgeons 
operate  in  two  stages ;  this  is  required,  however,  only  in  exceptional  cases 
when  infection  is  present  to  such  a  degree  as  to  endanger  extension  to  the 
peritoneum.  In  these  cases  the  safest  plan  is  to  wait;  suitable  gauze 
dressing  and  bandage  are  now  applied  over  the  external  wound  and  the 
patient  is  removed  from  the  operating  table.  Three  or  four  days  suffices 
to  form  complete  adhesion  between  the  tissues  and  to  wall  off  all  danger 
of  infection  of  the  peritoneum.  The  gauze  packing  will  also  become 
loosened,  which  permits  its  easy  removal,  and  the  patient  is  ready  for  the 
second  stage  of  operation.  As  a  matter  of  safety,  the  wound,  or  lower 
portion  at  least,  should  be  again  packed  loosely  with  iodoform  gauze. 
The  gallbladder  may  now  be  incised  and  stones  removed,  after  which  a 
glass  tube  with  iodoform  gauze  packed  around  it  is  inserted  for  the  pur- 
pose of  drainage  and  thus  a  cholecystostomy  is  done.  Many  surgeons 
make  extensive  use  of  this  operation  because  they  lay  great  weight  on 
drainage  of  the  bile-passages.  By  using  Morrison's  method  for  drain- 
age where  leakage  is  inevitable,  a  rubber  tube  is  inserted  through  the 
wound  in  front  and  extends  to  the  deepest  part  of  the  gallbladder,  or  the 
gallbladder  may  be  drawn  over  the  tube  as  far  as  deemed  necessary,  and 
fastened  by  means  of  a  strip  of  iodoform  gauze  wrapped  around  the  tube 
including  the  gallbladder  tissue,  thus  preventing  all  leakage.  The  rest  of 
the  wound  is  carefully  packed  with  iodoform  gauze. 

Many  very  serious  cases  thus  treated  have  resulted  ultimately  in  per- 
fect recovery.  In  chronic  inflammation  with  calculi  but  no  pus,  Ross 
passes  a  tube  into  the  bladder,  stitches  the  opening  firmly  around  the 
outer  wall  of  the  tube,  packing  the  wound  with  iodoform  to  wall  off  the 
peritoneum.  Another  packing  is  put  in  at  the  bottom  of  Morrison's 
pouch ;  the  latter  is  removed  about  the  fourth  or  fifth  day  and  the  former 
in  one  week  or  ten  days,  when  the  impacted  stone  can  be  safely  removed. 

In  all  cases  of  protracted  icterus  special  stress  must  be  laid  upon  the 
most  careful  arrest  of  hemorrhage,  owing  to  possibility  of  a  fatal  reac- 
tionary hemorrhage  occurring  from  a  small  vessel.  Capillary  oozing  in 
these  cases  usually  appears  the  second  or  third  day  following  operation. 
Mayo  Robson  recommends  as  a  preventive  measure  the  use  of  calcium 
chlorid,  20  grains  or  more  every  four  hours  for  several  days  prior  to  the 
operation.  When  there  is  protracted  icterus,  instead  of  incising  the  gall- 
bladder, Kocher  recommends  choledocholithotripsy  with  the  fingers  or 
forceps.  This  can  be  performed  safely,  however,  only  when  the  stone  is 
soft  and  can  easily  be  grasped;  otherwise  the  open  method  must  be  em- 


OPERATIONS    ON    STOMACH,    J.IVKR,    ANJ)    INTESTINES. 


'93 


ployed,  relying  on  Jirm  gauze  jKicking  and  jjressure  lo  overcfjme  the 
hemorrhage.  Cholecystenterostomy,  so  far  as  after-treatment  is  con- 
cerned, is  a  much  better  procedure  than  cholecystotomy,  especially  if  the 
operation  is  performed  by  the  aid  of  a  Murjjhy  button  of  small  caliber. 
The  latter  has  been  shown  to  be  well  adapted  to  this  operation  because 


Fig.  6i. — Illustrates  Morrison's  Method  of  Drainage  of  the  Gallduct, 
SHOWING  First  Layer  of  Dressings  in  a  Fleshy  Subject. 


of  the  rapidity  and  the  ease  with  which  it  can  be  adapted  and  the  cer- 
tainty of  rapid  union  wdiich  it  offers;  and,  lastly,  it  allows  of  the  im- 
mediate closure  of  the  external  wound  and  saves  the  patient  the  un- 
pleasantness of  an  external  fistula. 

Since  the  postoperative  treatment  of  operations  upon  the  gallblad- 
14 


194  POSTOPERATIVE    TREATMENT. 

der  is  dependent  so  largely  upon  drainage,  I  deem  it  advisable  to  give 
in  detail  other  popular  methods. 

Kehr's  Method  of  Drainage  after  Operations  on  the  Gallbladder. 

— Kehr's  wide  experience  in  gallstone  sufgery  has  led  him  to  the  convic- 
tion that  it  is  wise  to  incise  and  sound  the  common  bileduct  in  every  case 
of  gallstone,  and  that  every  choledochotomy  should  be  followed  by  drain- 
age of  the  hepatic  duct.  This  procedure  combined  with  cholecystectomy 
has  given  the  best  results  and  the  safest  protection  against  recurrence, 
and  is  indicated  in  every  case  in  which  it  does  not  add  materially  to  the 
operative  dangers. 

Drainage  of  the  hepatic  duct  is  secured  by  inserting  a  rubber  drain- 
age-tube through  the  choledochotomy  incision  and  pushing  it  in  toward 
the  liver  for  the  distance  of  four  centimeters.  The  tube  is  fixed  to  the 
choledochotomy  wound,  and  the  remainder  of  the  wound  is  closed  by 
silk  sutures.  The  ends  of  all  the  sutures  are  left  long  to  permit  of  their 
withdrawal  at  a  later  period.  The  drainage-tube  is  then  surrounded 
with  gauze  strips  folded  lengthwise.  The  first  tampon  is  laid  over  the 
foramen  of  Winslow;  the  second,  firmly  over  the  surface  of  the  liver 
from  which  the  gallbladder  was  excised ;  the  third  above  the  cholecys- 
tectomy incision  on  the  ligamentum  hepatoduodenalis ;  and  the  fourth 
on  the  ligatures  of  the  cystic  arteries  and  ducts  and  the  sutures  of  the 
common  bileduct;  while  the  fifth  tampon  is  placed  between  the  drain- 
age-tube and  the  stomach  or  duodenum. 

Berger  thus  presents  his  conclusions  after  a  study  of  97  cases  of 
gallstone  in  which  drainage  was  employed  by  the  above  method  in  Kehr's 
private  hospital. 

1.  Drainage  of  the  hepatic  duct  is  to  be  preferred  to  incision  and 
subsequent  suture  of  the  duct,  because  (a)  it  exerts  a  curative  action 
on  the  coexisting  cholangitis;  (b)  it  permits  of  the  later  extraction  of 
stones  not  removed  at  the  time  of  the  operation;  and  (c)  it  can  be  per- 
formed more  quickly. 

2.  Drainage  of  the  hepatic  duct  is  generally  indicated  in  cases  of 
active  cholangitis,  and  in  the  cases  in  which  it  is  not  possible  to  remove 
all  the  stones  from  the  hepatic  and  common  ducts  at  the  time  of  the 
operation. 

3.  Drainage  of  the  hepatic  duct  is  also  advisable  after  every  case 
of  choledochotomy,  even  though  the  bile  is  clear  and  the  presence  of 
further  stones  cannot  be  demonstrated. 

4.  It  is  the  safest  and  best  procedure  to  be  employed  in  the  cases 


OPERATIONS    ON    STOMACH,    LIVKK,     AM)    INTKSTINES.  I95 

in  which  the  history  and  ( linicul  signs  point  to  stone  in  the  hih'ary  pas- 
sages but  in  whicli  no  stone  is  found  at  the  time  oi  the  operation.  Jt 
is  also  to  be  recommended  in  every  case  of  choleh'thiasis,  provided  the 
operative  dangers  are  not  too  greatly  increased  thereby.  ' 

5.  It  is  contraindicated  in  cases  of  acute  suppurative  cholecystitis 
on  account  of  the  dangers  of  spreading  infection.  Exception  may  be 
made  to  this  rule  when  the  patient  behaves  badly  under  the  anesthetic 
and  tends  to  become  cyanotic  when  the  tissues  in  the  depth  of  the  wound 
are  handled. 

6.  Drainage  of  the  hepatic  duct  may  be  comparatively  easy  or  ex- 
tremely diiiicult,  depending  upon  the  conditions  found  at  the  time  of 
the  operation.  The  best  location  for  the  incision  is  in  the  supraduo- 
denal portion  of  the  duct.  Firmly  fixed  concretions  must  be  removed 
by  special  incisions  (hepaticotomy,  papillotomy).  Fistulas  should  not 
be  allowed  to  close  until  the  bile  is  clear  and  the  surgeon  feels  convinced 
that  all  iniiammation  has  subsided  and  that  no  more  stones  are  lodged 
in  the  hepatic  or  common  ducts. 

7.  The  results  of  drainage  of  the  hepatic  duct  are  extremely  satis- 
factory. It  not  only  prevents  further  extension  of  an  existing  cholan- 
gitis, but  it  also  brings  about  a  cure.  It  permits  of  the  subsequent  ex- 
traction of  stone  in  about  1 7  percent  of  all  cases,  and  thereby  prevents 
recurrence,  which  could  not  have  been  avoided  after  suture  of  the  chole- 
dochotomy  incision. 

8.  The  benefits  to  be  derived  from  drainage  of  the  hepatic  duct 
are  not  unlimited.  It  is  valueless  in  cases  of  diffuse  cholangitis  and  in 
cases  in  which  numerous  gallstones  occupy  a  position  high  up  in  the  liver. 

9.  Drainage  of  the  hepatic  duct  is  not  in  itself  an  especially  danger- 
ous operation.  In  uncomplicated  cases  its  mortality  (from  pneumonia, 
vomiting  of  blood,  and  acute  dilation  of  the  stomch)  is  not  more  than 
2  or  3  percent. 

10.  Complications,  such  as  extensive  cholangitis,  long-continued 
icterus  and  cholemia,  extensive  adhesions,  hepatic  cirrhosis,  pancreatic 
affections,  and  fistula  formation  between  the  biliary  system  and  the 
alimentary  tract,  increase  the  mortality. 

11.  In  cases  of  cholangitis,  carcinoma  of  the  pancreas  or  biliary 
passages,  and  suppurative  hepatitis,  the  mortality  is  nearly  100  per- 
cent. The  high  mortality  in  these  cases  cannot  be  ascribed  to  the 
operative  procedure,  but  is  due  to  the  too  long-continued  medical  treat- 
ment or  to  the  nature  of  the  aft'ection. 


196  POSTOPERATIVE    TREATMENT. 

12.  Early  operation  affords  the  best  chances  of  lowering  the  per- 
centage of  fatalities. 

Cook's  Method  for  Drainage  of  the  Gallbladder. — A  simpler 
method  for  drainage  of  the  gallbladder  after  cholecystostomy  is  the  one 
devised  and  practised  by  George  J.  Cook.     It  is  performed  as  follows: 

The  drainage-tube  employed  should  be  of  large  caliber  and  possess 
firm  walls  so  as  to  be  not  easily  compressed.  Its  proximal  end  is  firmly 
fixed  in  the  gallbladder  by  a  purse-string  suture.  Its  distal  end  should 
not  project  more  than  one  and  one-half  to  two  inches  beyond  the  edges 
of  the  wound.  To  this  end  is  firmly  tied  an  extra  large  and  extra  thick 
condom  or  rubber  sac.  The  gauze  dressings  are  next  applied;  upon 
these  is  placed  the  condom  or  rubber  sac,  and  this  is  well  surrounded 
and  covered  with  cotton.  All  are  retained  in  position  by  a  binder 
bandage  snugly  adjusted.  It  can  readily  be  seen  that  by  this  method 
we  have  produced  an  artificial  gallbladder  and  it  lies  in  close  proximity 
to  the  gallbladder  which  is  to  be  drained.  This  so-called  artificial 
gallbladder  is  removed  once  or  twice  every  twenty-four  hours,  emptied, 
and  thoroughly  cleansed,  after  which  it  is  again  placed  in  position. 

After  the  fourth  to  the  sixth  day  the  tube  and  iodoform  gauze  may 
be  removed,  and  if  there  is  no  obstruction  of  the  gallducts,  the  fistulous 
tract  may  now  be  permitted  to  heal  by  granulation.  One  of  the  greatest 
drawbacks  to  the  open  method  of  treatment  is  the  time  required  for 
the  wound  to  heal,  six  to  eight  weeks  being  usually  necessary. 

After-treatment. — Following  operations  on  the  gallbladder  or 
bileducts  considerable  pain  and  nausea  and  Vomiting  for  several 
hours  are  common.  Hence  nothing  but  small  quantities  of  hot  water 
should  be  given  by  the  mouth  for  twenty- four  hours;  a  hypodermatic  in- 
jection of  morphin  and  strychnin  may  be  advisable  immediately  after 
the  operation,  with  rectal  feeding  for  a  few  days.  Attention  to  the 
bowels  and  fluid  diet  are  practically  the  same  as  have  been  referred  to 
under  laparotomy. 

When  the  common  duct  has  been  incised  or  the  gallbladder  opened, 
the  dressings  should  be  changed  frequently  and  dry  sterilized  gauze 
applied  at  each  dressing.  The  sutures  are  removed  in  due  course  and 
the  drainage-tube  is  dispensed  with  as  soon  as  the  fistulous  tract  ap- 
pears to  be  sufficiently  sound.  This  will  probably  be  at  the  end  of  a 
week  or  ten  days.  The  sinus  should  be  frequently  washed  out  and 
the  parts  kept  scrupulously  clean.  T'he  fistula  usually  closes  without 
complication  in  from  three  to  four  weeks.     In  many  instances,  how- 


OPERATIONS   ON   STOMACH,    LIVER,    AND   INTESTINES.  I97 

ever,  it  remains  patent  for  months  or  years.  Mayo  reports  that  a  few 
patients  upon  whom  a  cholecystotomy  has  been  performed  suffer  from 
slight  colic  and  sometimes  transient  jaundice  during  the  first  month 
or  two  after  discharge  from  the  hospital.  These  symptoms  he  considers 
due  to  the  inability  of  an  adherent  gallbladder  properly  to  empty  itself. 
In  most  cases  no  secondary  operation  or  special  treatment  is  required. 
For  persistent  biliary  fistula  the  fistulous  tract  should  be  firmly 
packed  daily  with  5  percent  iodoform  gauze  dipped  in  balsam  of  Peru, 
over  which  a  firm  compress  is  applied,  or  if  granulations  appear  slug- 
gish, silver  nitrate  may  be  used.  Though  often  very  slow  in  healmg, 
a  permanent  fistula  is  rare,  except  when  the  gallbladder  has  been 
wrongly  attached  directly  to  the  skin,  in  which  case  a  slight  resection  of 
the  parts  usually  becomes  necessary  before  healing  will  result. 

ABSCESS  OF  THE  LIVER. 

Postoperative  Treatment. — The  postoperative  procedure  suggested 
by  Thomas  L.  Rhoades,  U.  S.  A.,  has  proved  of  such  marked  satis- 
faction in  our  hands  that  we  give  in  detail  his  method  of  after-treat- 
ment, as  well  as  that  portion  of  the  technic  essential  to  a  proper  under- 
standing of  the  same. 

The  liver  being  exposed,  taking  for  granted  that  no  adhesions 
exist  between  it  and  the  diaphragm,  narrow  strips  of  sterile  gauze  are 
packed  snugly  all  around  the  incision  through  the  diaphragm,  and  be- 
tween it  and  the  upper  surface  of  the  liver,  thus  walling  oiJ  the  peri- 
toneal cavity.  No  attempt  is  made  to  suture  the  nonadherent  liver 
to  the  diaphragm,  for  the  gland  is  too  friable  to  retain  sutures  of  any 
material,  and  in  the  several  cases  in  which  this  was  tried  all  the  sutures 
tore  through  the  tissue  immediately  on  a  slight  amount  of  tension  being 
used  to  approximate  the  two  surfaces. 

That  part  of  the  liver  is  now  exposed  for  operation,  and  bounded 
by  the  gauze  strips,  should  be  as  low  down  as  the  location  of  the  abscess 
will  permit,  to  allow  for  subsequent  liver  contraction  and  the  relative 
change  of  surface  levels — a  consideration  in  the  final  stage  of  drainage. 
The  liver  is  incised  with  a  knife,  a  closed  clamp  is  pushed  through  the 
intervening  structure  into  the  abscess,  is  opened,  and  withdrawn.  The 
patient  is  turned  gently  on  his  back  to  facilitate  the  flow  of  pus,  and 
when  this  has  ceased,  the  cavity  is  examined  and  cleansed.  Strips  of 
gauze  and  a  firm  drainage-tube  of  large  caliber  are  passed  into  the 
cavity,  the  tube  being  anchored  on  the   skin-surface  by  a  stitch,  and 


198  POSTOPERATIVE    TREATMENT. 

knots  of  white  and  black  sterile  silk  are  used  to  mark. the  ends  of  the 
gauze  strips  passing  into  the  liver,  and  those  packed  around  the  open- 
ing through  the  diaphragm.  These  ends  are  brought  out  of  the  wound 
at  the  posterior -angle,  alongside  the  rubber  tube;  several  additional 
strips  are  packed  in  the  wound  superficially  to  retain  an  opening  through 
the  chest  wall  at  least  5  cm.  in  diameter,  and  the  remainder  of  the  skin 
flap  is  sutured  in  position  with  silkworm-gut.  The  dressing  will  con- 
sist of  two  parts:  A  single  pad  of  sterile  gauze  for  the  exploratory  in- 
cision, covered  over  with  sterilized  guttapercha  or  oiled  silk,  the  edges 
of  which  overlap  the  gauze  pad  and  become  glued  to  the  skin ;  and  a 
generous  arrangement  of  gauze  and  cotton  pads  built  around  and  over 
the  ends  of  the  gauze  drains  and  tube.  A  single  broad  binder  from 
axilla  to  pelvis  retains  the  whole  in  position.  Time  for  both  operations 
— exploration  and  rib  resection — forty-five  minutes. 

After-treatment. — Judicious  management  of  the  postoperative 
period  is  most  important,  for  on  it  will  depend  the  ultimate  outcome 
of  the  case.  Individual  methods  of  handling  conditions  differ  widely, 
and  that  surgeon  will  secure  the  best  results  who  adheres  to  methods, 
medicaments,  and  food-stuffs  found  most  reliable  under  similar  con- 
ditions in  years  of  experience. 

My  general  plan  is  to  administer  morphin  sulfate  ^  grain  and  atro- 
pin  sulfate  -^--g-Q  grain  to  the  patient  after  consciousness  has  returned, 
to  allay  pain  and  combat  shock.  If  much  blood  was  lost  during  the 
operation,  saline  transfusion  will  have  been  given  on  the  table ;  and  if 
shock  is  deep,  application  of  dry  heat  and  an  enema  of  250  c.c.  of  hot 
coffee  will  control  it.  Hot  tea,  which  is  acceptable  to  the  stomach 
and  dissipates  the  ether  more  rapidly,  is  sipped  about  four  hours  after 
returning  to  bed.  Later  in  the  day  and  on  succeeding  days,  especially 
if  there  is  nausea  or  vomiting,  iced  ginger  ale,  lemonade,  albumen- 
water,  or  a  sherry  cobbler  may  be  taken  as  beverages. 

Free  discharge  will  necessitate  change  of  dressings  about  eight 
hours  after  operation,  at  which  time  the  entire  dressing  is  removed  and 
clean  gauze  and  cotton  are  reapplied,  the  patient  remaining  in  bed. 
On  the  following  five  days  the  dressing  is  changed  twice  a  day,  the  pa- 
tient being  lifted  into  a  rolling  litter  and  taken  to  an  adjoining  room 
each  time,  so  that  bed-linen  and  mattress  can  be  changed  and  aired. 
On  these  occasions  the  new  dressing  is  applied  after  washing  off  the  skin- 
surface  with  water  and  alcohol,  but  the  drainage  is  not  disturbed. 
During  the  first  six  days,  the  time  when  fibrous  adhesions  are  forming 


OPERATIONS    ON    STOMACH,    IJVKR,    AND    INTESTINES.  i(j() 

between  the  surfaces  around  tlic  f^au/e  packing,  ihc  patient  is  kept 
mildly  under  the  inlluence  of  an  opiate — either  morphin  sulfate,  ,!; 
grain,  or  Dover  powder,  f^  grain,  morning  and  afternoon — to  promote 
restfulness  and  allay  pain,  but  not  in  sufficiently  large  dose  to  act  as  a 
hypnotic'  Effects  on  the  nervous  system  in  each  case  will  determine 
the  dosage.  On  the  sixth  day  adhesions  will  have  formed,  and  the 
gauze  dramage  and  rubber  tube  will  be  surrounded  by  a  fibrinous  ex- 
udate and  lymph,  which,  on  removal  of  the  drains,  Avill  have  estab- 
lished a  secure  pathway  from  skin-surface  to  abscess-cavity.  The  gauze 
strips  and  rubber  tube  can  therefore  be  removed  with  safety.  The 
ends  of  the  gauze  projecting  from  the  wound  are  clamped  on  forceps, 
and  by  twisting  and  tugging  are  removed  in  separate  pieces.  The  tube 
is  likewise  withdrawn.  With  the  aid  of  a  stout,  bent  glass  tube  hav- 
ing a  lumen  0.5  cm.  in  diameter,  the  cavity  is  irrigated  with  warm 
sterile  water  until  the  flow  returns  clear.  A  new  rubber  tube,  similar  to 
the  one  removed,  is  carried  into  the  cavity,  the  depth  of  insertion  being 
regulated  by  a  sterilized  safety-pin  transfixing  its  external  end.  Strips 
of  sterile  gauze  are  packed  around  the  tube  down  to  the  abscess  cavity, 
dressings  are  applied,  and  the  patient  is  returned  to  bed.  This  process 
is  continued  on  each  successive  day,  a  clean  tube  and  new  strips  for 
drainage  being  inserted  after  irrigation,  until  there  is  no  further  evi- 
dence of  pus;  all  packing  and  drainage  are  then  discarded,  and  the 
sinus  is  allowed  to  close.  The  patient  is  permitted  to  sit  on  a  rolling 
chair  in  a  reclining  posture  after  the  second  week,  and  during  the  last 
days  of  local  treatment  will  be  walking  about — providing,  of  course, 
systemic  conditions  are  favorable. 

Anemic  patients  about  ten  days  after  operation  are  given  thrice 
daily  on  an  empty  stomach  30  c.c.  of  pure  olive  oil  in  a  wineglass,  into 
the  bottom  of  which  is  squeezed  10  c.c.  of  lemon-juice.  The  oil  should 
be  of  pure  variety,  the  product  of  the  press  when  the  fruit  is  nearly 
ripened,  so  as  to  lessen  the  tendency  to  nausea.  This  amount  can  be 
increased  to  60  c.c.  or  90  c.c.  three  times  daily  in  the  course  of  a  week, 
without  causing  any  gastric  disturbance,  which  dose  is  then  continued 
for  weeks  until  all  evidence  of  dysentery  has  disappeared,  a  time  which 
is  necessarily  variable.  Patients  soon  acquire  a  taste  for  the  oil,  and 
those  to  whom  it  was  distasteful  at  the  onset  of  the  treatment  have  later 
been  seen  to  crave  it.  Under  its  influence  they  gain  rapidly  in  weight, 
color,  and  vigor.  Patients  reduced  to  the  neighborhood  of  90  pounds 
and  who  were  bedfast  for  months,  have  increased  in  weight  from  40 


200  POSTOPERATIVE    TREATMENT. 

to  50  pounds  in  six  weeks'  time,  taking  daily  walks  in  the  open  air. 
The  effect  on  the  intestinal  dejections  is  the  most  notable  feature  of 
the  treatment.  The  oil  acts  beneficially  principally  by  stimulating 
the  portal  circulation,  increases  the  flow  of  bile,  restores  a  natural  diges- 
tive agent  and  antiseptic  to  the  intestinal  canal,  and,  combined  with 
the  bile,  protects  and  promotes  healing  of  the  ulcers. 

Feeding  is  an  equally  important  matter,  and  at  the  beginning  of 
convalescence,  a  proper  dietary  must  be  selected  which  will  build  up 
the  patient,  increase  his  powers  of  resistance,  and  while  generous  in 
quantity  must  not  overwhelm  his  digestive  powers.  Milk  and  all  ar- 
ticles of  food  prepared  with  milk  (soups,  gruels,  etc.)  are  proscribed. 
The  diet  on  which  these  patients  thrive  best,  and  gain  most  rapidly, 
is  one  of  solid  food,  given  in  conjunction  with  the  administration  of 
olive  oil.  Salads  and  shellfish  are  usually  most  grateful,  and,  together 
with  minced  meats  and  well-cooked  vegetables,  constitute  the  most 
desirable  dietary. 


GASTROTOMY,  GASTROSTOMY,  PYLORECTOMY. 

General  Remarks. — Many  forms  of  incision  have  been  advised 
and  carried  out.  Some  have  employed  an  incision  in  the  median  line, 
others  a  vertical  incision  in  the  left  linea  semilunaris.  Sedillot  used  a 
cross-cut  below  the  xiphoid  cartilage.  Howse  prefers  a  vertical  inci- 
sion in  the  sheath  of  the  rectus,  a  little  to  the  inner  side  of  its  outer 
border.  The  vertical  fibers  of  the  rectus  are  exposed  and  are  separated 
(not  cut)  with  the  handle  of  the  scalpel.  The  posterior  part  of  the 
sheath  is  thus  reached.  It  is  divided  vertically,  and  the  abdominal 
cavity  opened.  The  incision  has  the  disadvantage  of  bringing  the 
wound  area  somewhat  closer  to  the  pyloric  region.  In  carrying  out 
the  incision  it  should  be  remembered  that,  owing  to  the  emaciation  of 
the  patient  and  the  sunken  condition  of  the  abdomen,  the  part  of  the 
abdomen  attacked  is — as  the  patient  lies  upon  the  back — almost  ver- 
tical. The  integument,  after  passing  over  the  margin  of  the  ribs, 
turns  suddenly  backward  toward  the  spine,  following  the  sunken 
abdominal  wall. 

In  gastrostomy  several  methods  have  been  "invented"  of  fixing 
the  pouch  of  stomach  obliquely  through  the  abdominal  wall  and  then 
opening  the  extreme  upper  end  of  this  tubular  process,  a  catheter 
being  secured  in  the  usual  way.     They  cannot  be  described  here,  but 


*      OPERATIONS    ON  STOMACH,    LIVER,    AND    INTESTINES.  20I 

the  postoperative  treatment  applies  to  all.  The  many  different  methods 
adopted  of  feeding  the  patient  only  serve  to  emphasize  the  fact  that 
no  rigid  rule  can  be  adhered  to,  and  that  this  factor  in  the  after-treat- 
ment must  be  modified  according  to  the  particular  circumstances  of 
each  case. 

Feeding  of  the  Patient  and  After-treatment.— The  amount  of 
food  introduced  on  the  occasion  when  the  stomach  is  opened  must  depend 
upon  the  patient's  condition.  If  no  food  has  been  swallowed  for  a 
considerable  period,  it  will  suffice  at  first  to  introduce  only  a  few  drams 
of  milk  mixed  with  a  little  brandy.  The  quantity  can  be  gradually 
increased.  If,  however,  the  patient  has  been  able  to  take  some  food 
through  the  gullet  up  to  the  time  of  the  operation,  his  first  meal  may 
consist  of  from  two  to  four  ounces  of  a  mixture  of  milk,  egg,  and  brandy. 
This  is  slowly  poured  in  through  the  funnel,  the  gauze  covering  of  which 
prevents  any  semisolid  particles  from  entering  and  blocking  the  tube. 
A  pad  of  soft  gauze  packed  around  the  aperture  in  the  stomach  will 
absorb  any  fliuid  which  may  escape.  As  a  matter  of  fact,  however,  such 
escape  is  very  seldom  to  be  anticipated. 

After  the  feeding  the  tube  is  left  in  place.  It  is  secured  to  the  ribs 
in  the  form  of  a  coil  by  means  of  strips  of  plaster.  Its  end  is  left  open, 
and  serves  to  afford  escape  to  any  fluid  which  the  stomach  might  at- 
tempt to  reject.  This  open  end  is  received  by  a  pad  of  absorbent  wool 
or  the  tube  may  be  closed  in  the  intervals  of  feeding  by  a  Hght  clamp. 
The  skin  around  the  margin  of  the  "stoma"  is  kept  clean  and  dry,  is 
smeared  with  lanolin,  and  well  dusted  with  sodium  bicarbonate. 

The  feeding  should  be  repeated  frequently;  the  amount  given  is 
slowly  increased,  but  the  quantity  administered  each  time  should  be 
small. 

The  diet  will  consist  of  milk,  eggs,  beef-tea,  soups,  tea,  cocoa,  cer- 
tain prepared  foods,  and  a  proper  allowance  of  water.  All  food  ad- 
ministered should  be  of  the  temperature  of  the  body.  As  time  advances, 
more  food  may  be  given,  but  at  less  frequent  intervals.  The  fistula 
may  in  process  of  time  become  enlarged,  and  then  very  finely  minced 
meat  and  pulped  vegetables  may  be  introduced  into  the  stomach  by 
means  of  a  suitable  syringe.  On  the  other  hand,  a  tendency  to  con- 
tract is  sometimes  shown,  and  must  be  overcome  by  occasional  dilation 
with  a  seatangle  tent.  The  patient's  own  feelings  afford  the  best  guide 
to  the  value  of  certain  foods  and  the  amount  and  mode  of  their  admin- 
istration. It  will  often  be  found  that  the  patient  after  gastrostomy  is 
able  to  swallow  with  grreater  ease  for  a  time. 


202  POSTOPERATIVE    TREATMENT. 

Leakage  of  gastric  juice  and  regurgitation  of  food  are  often  due 
to  the  stomach  having  been  opened  too  near  to  the  pylorus.  The  pa- 
tient who  is  the  subject  of  such  trouble  should  be  fed  in  the  recumbent 
position,  and  lying  upon  the  left  side.  Leakage  may  also  be  due  to 
the  gastric  opening  having  been  made  too  large. 

The  irritation  produced  by  the  escape  of  gastric  juice  is  best  met 
by  constant  attention  to  cleanliness,  by  the  very  frequent  changing  of 
dry  absorbent  pads,  and  by  the  liberal  powdering  of  the  part  with 
sodium  bicarbonate. 

OPERATIONS  UPON  THE   INTESTINES  AND  USE  OF  THE 
MURPHY  BUTTON.     (MURPHY.) 

The  Murphy  button  should  be  used  only  for  end-to-end  or  end-to- 
side  approximation  in  the  small  intestines,  an  end-to-side  or  side- 
to-side  approximation  of  the  large  intestines,  as  well  as  side-to-side 
approximation  of  the  jejunum  or  duodenum  to  the  stomach.  For  a 
gastroenterostomy  Murphy  prefers  the  posterior  operation  and  the 
oblong  button.  In  the  stomach  it  prevents  subsequent  closure.  One 
of  the  important  factors  in  either  method  of  approximation,  particularly 
in  acute  intestinal  obstruction,  is  to  remove  a  number  of  inches  or  even 
feet  of  the  bowel  on  the  proximal  side  of  the  occlusion.  The  bowel  in 
this  condition  is  often  infiltrated,  ulcerated,  or  bordering  on  necrosis, 
and  unless  a  sufi&cient  extent  is  resected,  there  will  be  a  failure  of  union, 
no  matter  what  method  is  employed.  In  acute  obstruction  the  con- 
tents of  the  bowel  above  the  obstruction  should  be  allowed  to  flow  out 
at  the  time  of  the  operation.  When  much  work  or  manipulation  is 
done  in  the  abdominal  cavity,  particularly  with  bullet  wounds,  drain- 
age should  be  instituted  and  the  patient  placed  in  a  sitting  position. 
The  abdomen  should  never  be  flushed.  Excess  of  sponging,  packing, 
and  manipulation  of  the  intestines  increase  the  danger  of  shock  and 
infection. 

After  the  use  of  the  Murphy  button  liquid  nourishment  is  adminis- 
tered eight  hours  after  the  patient  recovers  from  the  effects  of  anes- 
thesia. This  nourishment  does  not  include  milk;  and  no  solid  food 
is  allowed  until  the  button  passes.  Morphin  is  practically  never  used 
after  laparotomy  in  Murphy's  work.  In  a  general  way  the  after-treat- 
ment corresponds  with  that  employed  after  gastroenterostomy,  with  a 
difference  that  food  is  given  by  mouth  a  little  earlier,  and  that  active 
cathartics  are  not  given  until  the  button  is  passed.     If  the  colon  is  in- 


OPERATIONS    ON   STOMACFF,    LIVKR,    AND    INTESTINES. 


203 


Fig.  62. 


volved  in  the  opcnition,  ])rcdigestcd  foods  arc  given  by  nifjuth  horn 
the  third  day  on,  but  ncjurishment  by  enema  is  not  employed.  One  can 
easily  choose  a  prcdigested  food  which  is  absorbed  almost  entirely  from 
the  stomach,  which  will  sustain  the  i)atient  unlil  ihe  union  between 
the  united  ends  of  the  intestine  is  sufliciently  safe  to  make  use  of  a  gen- 
eral diet.  Ordinarily, 
firm  union  exists  after 
the  third  day,  but 
many  patients  in 
whom  these  opera- 
tions are  indicated 
are  much  reduced  in 
strength,  and  conse- 
quently their  tissues 
do  not  heal  so  rapidly; 
and  in  such  conditions 
alcoholic  stimulants 
are  imperative. 

The  length  of  time 
the  button  may  be 
retained  in  the  intes- 
tinal canal  varies 
greatly.  It  usually 
passes  in  seven  to 
fourteen  days.  In 
some  cases  several 
weeks  may  have 
elapsed  before  it  ap- 
pears in  the  rectum. 
Its  presence  and  po- 
sition in  the  abdomen 
can,  of  course,  be  as- 
certained by  skia- 
graphy. When  the 
button  remains  in  the 
intestine,  unless   it  is 

giving  manifestations  of  irritation,  which  it  rarely  does,  it  should 
never  be  disturbed.  It  can  usually  be  found  situated  in  the  rectum, 
just  above  the  internal  sphincter,  after  seven  to  ten  days,  and  when  it 
can  be  felt  bv  digital  examination  it  is  extracted  with  forceps. 


Fig.  65 


-^TT^'^wpm- 


Fig.  64. 
Figs.  62  to  64. — End-to-end  Approximatiox  with  Mxjr- 
PH!^  Button  held    in    Position  by    Purse-string 
Sutures. — (Binnie,  after  Da  Costa.) 


204 


POSTOPERATIVE    TREATMENT. 


COLOSTOMY. 
Considerations  of  Technic. — The  operation  of  colostomy  for  the 
purpose  of  establishing  an  artificial  anus  is  performed  in  two  ways. 
The  most  common  practice  is  as  follows:  The  colon  is  drawn  out 
through  an  incision  in  the  abdominal  wall,  its  mesentery  split,  and  a  flap 
of  skin  is  cut  and  drawn  through  the  slit  in  the  mesentery  and  sutured 
in  place.     The  upper  segment  of  the  intestine  is  then  drawn  outward 


/.fflBp^^Ssi 


■■•lii 


Fig.  65. — Macewen's  Sutures  to  Draw  the  Conjoined  Tendons  to  Poup art's 
Ligament. — {Moullin.) 


and  the  lower  segment  placed  inward,  and  the  skin-flap  drawn  through 
the  opening  in  the  mesentery.  In  this  manner  the  upper  segment  is 
bent  over  the  outer  edge  of  the  abdominal  wall  and  underneath  the  skin- 
flap  ;  consequently  after  healing  has  taken  place  the  application  of  a  pad 
over  this  part  will  cause  the  skin-flap  to  act  like  a  valve  and  prevent  the 
voluntary  evacuation  of  the  bowels.     In  order  to  prevent  protrusion, 


OPERATIONS    ON   STOMACH,    LIVKK,    AND    INTESTINES.  '  205 

several  stitches  arc  inserted,  attaching  the  intestine  to  the  skin.  The 
loop  of  the  intestine  is  not  opened  until  adhesions  have  formed,  unless 
this  is  necessary  on  account  of  complete  obstruction,  in  which  case  the 
wound  is  carefully  protected  and  a  large  rubber  tube  covering  a  short 
glass  tube  is  inserted  into  the  upper  segment  and  securely  fastened  by 
means  of  a  strong  purse- string  suture.  This  will  compel  the  contents 
of  the  intestines  to  pass  out  through  the  tube  which  passes  through  the 
center  of  the  dressings  without  soiling  the  wound.  If  immediate  open- 
ing of  the  intestine  is  not  necessary,  the  part  should  be  covered  with 
sterile  gauze  held  in  place  by  means  of  broad  adhesive  strips  and  ab- 
dominal bandages.  After  three  to  five  days  when  adhesions  have  thor- 
oughly formed  the  intestine  may  be  opened,  and  evacuation  of  the 
bowel  can  now  occur  without  interference  with  the  healing  of  the  wound. 

Another  method  is  to  draw  the  intestine  purposely  through  a  thick 
part  of  the  abdominal  wall  by  bringing  it  out  obHquely  rather  than 
directly  through  the  tissues,  by  choosing  the  muscular  part  so  that  the 
muscles  by  tension  and  contraction  may  keep  the  gut  closed,  and 
o'nly  give  under  the  pressure  and  force  exerted  by  the  peristaltic  con- 
traction of  the  intestine.  The  intestine  is  now  carefully  sutured  in 
position  and  allowed  to  granulate  for  forty-eight  to  seventy-two  hours, 
after  which  delay  the  bowel  is  opened  transversely  to  its  long  axis  so 
that  the  upper  end  shall  evacuate  its  contents  externally  directly  through 
the  opening.  If  the  artificial  anus  is  to  be  but  temporary,  it  is  prob- 
ably best  to  make  the  opening  in  the  long  axis  of  the  gut  rather  than 
transversely.  Some  surgeons — Hartman  and  others — do  not  suture  the 
intestine  at  all,  but  merely  pull  out  the  gut,  packing  a  piece  of  iodoform 
gauze  carefully  around  it  and  over  both  ends,  leaving  it  there  for  eight 
hours. 

After-treatment. — Ochsner  states  that  until  the  protruding  loop 
has  been  cut  only  hot  water  and  small  quantities  of  predigested  food 
are  given  by  mouth.  After  this  general  liquids,  and  after  a  week  light 
diet,  are  given. 

This  operation  is  usually  performed  in  old  persons  greatly  reduced 
in  strength,  and  these  do  not  bear  lying  quietly  in  bed.  It  is  conse- 
quently best  to  permit  them  to  occupy  a  semisitting  position  within  a 
day  or  two  after  the  operation  and  to  leave  the  bed  within  a  week  or 
ten  days  later.  After  the  intestine  has  been  opened  a  cathartic,  prefer- 
ably castor  oil,  should  be  given,  and  this  should  be  followed  by  several 
enemas  in  order  to  remove  fecal  accumulations  which  frequently  exist 


2o6  POSTOPERATIVE    TREATMENT. 

in  large  quantities  above  the  constriction,  even  if  a  diligent  attempt 
has  been  made  to  evacuate  the  bowels  before  operation.  Frequently 
the  lower  segment  contains  many  of  these  masses,  which  can  usually 
be  removed  by  irrigation,  but  may  occasionally  require  a  blunt  scoop 
for  their  removal.  It  is  well  to  examine  the  opening  by  inserting  the 
finger  within  the  lumen  of  the  intestine  through  the  abdominal  wall, 
because  occasionally  not  sufficient  space  has  been  allowed  for  the  evac- 
uation of  the  bowels  and  the  free  passage  of  gas.  This  can  be  rem- 
edied readily  by  a  slight  incision. 

These  patients  should  be  instructed  to  regulate  their  diet  so  as  to 
avoid  constipation,  and  then  to  take  a  simple  cleansing  enema  once 
a  day  to  insure  a  free  evacuation  of  the  bowels.  Thus  they  can  usually 
be  entirely  free  from  any  annoyance  because  of  the  artificial  anus.  A 
small  pad  of  cotton  should  be  worn  over  the  opening,  held  in  place  by 
a  simple  abdominal  bandage.  In  case  there  is  any  annoyance  from 
escaping  feces  a  substantial  pad  may  be  held  in  place  over  the  opening 
by  means  of  an  elastic  bandage  which  will  compress  the  intestine  under- 
neath the  skin-flap. 

If  there  is  not  enough  force  in  the  colon  to  effect  an  evacuation, 
it  is  sometimes  best  to  insert  a  large  rectal  tube  after  giving  the  enema 
and  to  effect  the  evacuation  through  this. 

Postoperative  Treatment  as  Recommended  by  Sir  Frederick 
Treves. — When  the  symptoms  are  not  urgent,  the  operation  of  colos- 
tomy is  usually  carried  out  in  two  stages  {colostomy  a  deux  temps). 
The  bowel  is  fixed  to  the  skin  by  numerous  superficial  sutures.  Care 
should  be  taken  that  no  suture  extends  through  the  mucous  lining  of 
the  bowel.  The  part  is  well  dusted  with  iodoform,  and  after  an  interval 
of  thirty-six  to  forty-eight  hours  the  operation  is  completed  by  opening 
the  colon. 

After-treatment. — The  actual  wound  is  dusted  with  iodoform, 
and  all  the  skin  around  is  well  covered  with  lanolin.  A  large  pad  of 
absorbent  wool  is  placed  over  the  artificial  opening,  and  retained  by 
means  of  a  many-tailed  bandage.  So  long  as  there  is  a  copious  escape 
of  fecal  matter  no  bandage  should  be  applied.  The  pad  of  wool  must 
be  changed  as  often  as  it  is  soiled,  and  the  exclusive  attention  of  one 
nurse  should  be  occupied  in  keeping  the  patient  always  clean. 

When  the  discharge  is  very  free,  a  pad  of  loose  "tenax,"  covered 
with  a  layer  of  wool,  will  be  found  to  be  more  convenient.  The  main 
feature  in  the  nursing  is  that  the  part  must  be  kept  dry.     The  skin 


OPERATIONS     ON     STOMA('I),     lAVKR,   AM)    IX'IKSTINES.  207 

should  not  1)C  ]'ubl)C(l  clfun,  but  slioulfl  Ijc  cicanscfl  l^y  a  stream  of  warm 
water,  which  is  received  in  a  kiflney  shajjcfl  Iray.  'I'his  method  in\'fjlves 
no  more  trouble  and  no  more  time  than  the  patting  and  rubbing  process 
which  is  carried  out  with  innumerable  pledgets  of  cotton-wool.  After 
each  washing  the  skin  is  very  gently  dried,  and  is  once  more  covererl 
with  lanolin.  If  the  wound  were  to  need  washing  every  fifteen  minutes 
during  the  first  day  or  so,  it  would  certainly  be  better  to  do  so  than  to 
allow  a  freshly  united  incision  to  remain  for  an  hour  or  more  poulticed 
with  fecal  matter. 

During  the  first  few  days  the  patient  should  keep  very  quiet,  should 
lie  upon  the  back,  or,  if  the  position  be  altered  at  all,  should  turn  over 
toward  the  wounded  side.  The  attachments  of  the  gut  will  be  dragged 
upon  if  the  patient  lie  upon  the  sound  side.  The  discharge  of  fecal 
matter  from  the  bowel  may  be  delayed  for  hours  or  even  for  days. 
The  opening,  as  already  stated,  is  at  first  very  small;  and  if  it  suffices, 
well  and  good.  If,  however,  hard  scybala  have  to  escape,  then  the 
opening  must  be  in  due  course  enlarged.  An  aperient  given  on  the 
fourth  or  fifth  day  after  the  operation  has  often  an  excellent  effect. 

Prolapse  of  the  gut  at  the  artificial  opening  is,  so  far  as  my  expe- 
rience goes,  but  rarely  met.  A  preliminary  small  opening  in  the  gut, 
primary  healing,  and  the  maintenance  of  a  healthy  condition  of  the 
mucous  membrane  appear  to  be  the  main  factors  which  assist  in  pre- 
venting this  complication.  The  skin  around  the  artificial  anus  may 
become  very  raw  and  inflamed.  This  is  especially  likely  to  be  the  case 
when  the  fistula  is  established  near  a  malignant  growth,  as  when  the 
colon  on  the  right  side  is  opened.  In  these  circumstances  a  frequent 
washing-out  of  the  bowel,  and  the  most  scrupulous  attention  to  the 
cleanliness  of  the  part,  will  effect  much. 

Properly  shaped  pieces  of  lint  soaked  in  oil  may  prevent  some  of 
the  fecal  matter  from  running  over  the  skin,  but  no  contrivance  that  I 
have  as  yet  seen  has  prevented  it  entirely.  The  disturbing  symptoms 
produced  by  the  presence  of  fecal  matter  in  the  colon  below  the  arti- 
ficial opening  may  be  relieved  by  the  systematic  washing- out  of  that 
part  of  the  bowel,  and  by  the  subsequent  closure,  if  need  be,  of  its  upper 
extremity. 

The  diet  in  these  cases  should  be  spare  and  nourishing,  and  of 
such  a  kind  as  to  leave  the  least  possible  residue  in  the  intestine.  The 
consumption  of  milk  in  considerable  quantity  appears  to  encourage 
the  formation  of  scybala.  A  liberal  amount  of  vegetable  matter  should 
be  a  feature  in  the  diet. 


2o8  POSTOPERATIVE    TREATMENT. 

After  the  wound  has  healed  and  the  recovery  from  the  operation 
is  complete,  the  patient  may  be  furnished  with  a  simple  belt  which 
will  permit  a  pad  of  wool  or  some  folds  of  linen  to  be  held  in  place 
when  the  patient  is  moving  about.  The  simpler  the  belt,  the  better; 
and  it  must  be  so  constructed  as  to  be  readily  unfastened.  The  various 
plugs,  cups,  bags,  and  pessaries  which  have  been  devised  for  the  use 
of  patients  after  colostomy  are,  so  far  as  I  have  seen,  more  or  less  use- 
less. After  a  short  trial  they  are  usually  abandoned  for  some  simple 
arrangement  of  cloths  or  pads  which  the  patients  have  themselves  de- 
vised. 

Colostomy  for  Acute  Obstruction. — In  cases  of  acute  obstruc- 
tion of  the  bowels  when  the  patient  is  greatly  exhausted  we  have  found 
the  method  of  rapid  or  temporary  colostomy,  as  devised  or  practised 
by  Franklin  H.  Martin,  to  be  not  only  very  simple,  but  highly  satis- 
factory, affording  rapid  relief  to  the  patient.  A  small  abdominal  in- 
cision is  made  under  local  anesthesia.  A  loop  of  distended  bowel  is 
pulled  through  and  out;  a  piece  of  gauze  is  passed  between  the  skin 
and  the  bowel  through  its  mesentery.  A  small  incision  is  made  into 
the  bowel  and  a  portion  of  the  Murphy  button  hastily  inserted  and 
attached  to  the  intestinal  wall.  The  other  or  outer  end  of  the  button, 
having  been  previously  covered  by  a  piece  of  rubber  tubing,  is  rapidly 
pushed  home,  the  discharges  from  the  bowel  being  conveyed  into  a 
pus-pan  or  vehicle.  Since  much  time  is  usually  lost  in  an  effort  to 
determine  which  is  the  upper  or  lower  end  of  the  bowel,  no  effort  is 
made  to  determine  this  question  at  this  time.  Later,  when  the  button 
comes  away,  the  direction  of  bowel  movement  can  be  easily  determined, 
and  by  this  time  the  patient,  having  recovered  strength,  a  laparotomy 
can  be  made  with  safety,  and  the  obstruction  removed  if  present,  or 
an  end-to-end  approximation  may  be  made  and  the  bowel  dropped 
into  the  abdominal  cavity.  This  operation  is  essentially  an  emergency 
one. 

INTESTINAL  OBSTRUCTION. 
Concerning  after-treatment  Nicholas  Senn  says:  Uniform  equa- 
ble support  of  the  abdomen,  by  strapping  and  bandages  over  the  anti- 
septic absorbent  dressing,  furnishes  efficient  support  to  the  distended 
abdominal  walls  and  the  paretic  intestines,  and  is  not  only  grateful 
to  the  patient,  but  is  an  important  aid  in  relieving  the  distress  due  to 
distention  and  peristalsis.     In  all  operations  for  intestinal  obstruction 


OPERATIONS    ON   STOMACH,    LIVKK,    AM)    INTESTINES.  209 

efforts  should  be  made  to  empty  the  l)owc],  not  only  at  the  seat  of  ob- 
struction, but  so  far  as  it  can  be  done  throughout,  as  such  immediate 
evacuation  constitutes  one  of  the  elements  of  success. 

J.  Greig  Smith  states  that  "no  case  of  operation  for  intestinal  ob- 
struction is  properly  concluded  until  the  distended  bowels  are  relieved 
of  their  contents."  One  of  the  most  favoral^le  symptoms  after  a  suc- 
cessful operation  for  intestinal  obstruction  is  a  spontaneous  action  of 
the  bowels,  as  it  not  only  proves  the  permeability  of  the  intestinal  canal, 
but  is  also  an  evidence  that  peristaltic  action  has  been  restored.  The 
retention  of  fecal  material  in  the  distended  paretic  intestines  after 
operation  for  intestinal  obstruction  is  a  condition  that  not  only  retards 
recovery,  but  is  in  itself  a  grave  source  of  danger.  Through  the  sym- 
pathetic nerves  the  distended  intestine  exerts  a  most  depressing  effect 
on  the  cerebrospinal  centers,  while  the  putrefactive  changes  that  are 
constantly  going  on  in  the  stagnant  intestinal  contents  must  be  a  con- 
stant source  of  intoxication,  and,  at  the  same  time,  the  migration  of 
septic  microorganisms  through  the  paretic  walls  threatens  hfe  from 
septic  peritonitis. 

Symptoms  of  shock  are  met  by  the  administration  of  strychnin 
subcutaneously,  stimulants  by  the  rectum,  intravenous  or  subcutaneous 
saline  infusions,  and  stimulation  of  the  peripheral  circulation  by  dry 
heat  applied  to  the  surface  of  the  trunk  and  extremities.  Mr.  Tait 
has  taught  us  the  value  of  cathartics  in  the  prevention  of  peritonitis 
after  abdominal  operations.  Would  it  not  be  rational  to  follow  his 
example  in  the  after-treatment  of  operations  for  intestinal  obstruction  ? 
Surgeons  have  repeatedly  made  the  observation  that  the  paretic  intes- 
tine above  the  seat  of  obstruction  will  respond  slowly  but  surely  to 
mechanical  irritation,  and  it  is  logical  to  conclude  that  the  same  effect 
would  be  produced  by  the  administration  of  a  brisk  sahne  cathartic. 
Dangerous  as  the  use  of  cathartics  necessarily  must  be  before  the  ob- 
struction is  removed,  so  beneficial  may  their  judicious  employment  be 
after  the  continuity  of  the  intestinal  canal  has  been  restored  by  ope- 
rative treatment. 

Feeding,  etc. — Thirst  is  quenched  by  sips  of  hot  water,  fragments 
of  ice,  and  saline  rectal  enemas.  Stomach-feeding  is  absolutely  con- 
traindicated  for  the  first  forty-eight  or  seventy-two  hours,  during  which 
time  rectal  alimentation  is  relied  upon  exclusively.  Absolute  rest  in 
the  recumbent  position  must  be  enforced  until  the  visceral  and  abdom- 
inal wounds  have  healed.  The  administration  of  copious  laxative 
15 


2IO  POSTOPERATIVE    TREATMENT. 

enemas  is  permissible  for  the  purpose  of  assisting  the  saHne  cathartics 
to  restore  peristalsis,  provided  the  seat  of  strangulation  was  above  the 
ileocecal  valve. 

Postoperative  Enterostomy. — Enterostomy  for  the  purpose  of 
feeding,  or  in  cases  of  intestinal  paresis,  is  to  be  recommended  espe- 
cially for  temporary  use,  and  it  should  be  resorted  to  under  none  but 
urgent  indications,  the  disadvantages  of  an  intestinal  fistula  being 
manifest.  The  operation  requires  but  a  fev^  minutes  and  is  readily 
performed  under  local  anesthesia. 

The  technic  of  the  operation  varies  somewhat,  depending  upon 
whether  it  is  primary  or  secondary  to  another  operation,  or  whether 
the  fistula  is  to  be  used  for  feeding  alone  or  for  drainage  as  well.  If 
for  the  purpose  of  feeding  only,  the  method  introduced  by  Witzel  for 
gastrostomy  is  perhaps  the  one  to  be  chosen.  R.  Follis,  Resident  Sur- 
geon of  the  Johns  Hopkins  Hospital,  has  reported  a  method  for  the 
production  of  a  temporary  intestinal  fistula  which  we  believe  offers 
an  advantage  over  any  other  with  which  we  are  familiar,  in  that  the 
intestines  may  be  opened  immediately  with  less  risk  of  soiling  the  peri- 
toneum.    These  fistulas  generally  close  spontaneously. 

We  have  generally  proceeded  as  follows :  The  selected  loop  of  bowel 
is  brought  out  and  iodoform  gauze  is  packed  around  it  to  wall  it  off  from 
the  general  peritoneal  cavity.  This  loop  may  be  opened  immediately, 
or  if  the  patient's  condition  admits  of  delay,  sufficient  time  may  be 
allowed  for  the  formation  of  protective  adhesions.  After  the  opening 
has  been  made  a  rectal  tube  is  inserted,  first  in  one  direction  and  then 
in  the  other,  and  may  usually  be  passed  several  feet  either  way.  This 
will  allow  the  escape  of  gas  and  feces  from  the  distended  bowel,  and 
through  it,  when  necessary,  a  considerable  segment  of  the  intestine  may 
be  irrigated.  So  soon  as  the  intestine  has  been  opened  and  the  tube 
is  inserted  we  generally  inject  a  quantity  of  salt  solution  in  both  direc- 
tions, and  by  watching  can  usually  determine  which  is  the  distal  por- 
tion. After  the  distal  segment  has  been  determined,  one  can  begin 
at  once  the  administration  of  stimulating  or  nutritive  enemas  through 
the  fistula.  The  amount  of  fluid  that  can  be  given  in  twenty-four 
hours  and  retained  is  surprisingly  large.  Water  or  coffee  infusion, 
peptonized  milk,  eggs,  and  prepared  foods  in  any  desirable  quantity 
can,  through  the  tube,  be  placed  in  the  intestine  several  feet  from  the 
opening,  and  by  gravity  or  hydraulic  pressure  be  forced  onward  into 
a  collapsed,  atonic  bowel.     Purgatives,  such  as  castor  oil,  salts,  croton 


OPERATIONS   ON   STOMACH,    LIVFCR,   AND    INTESTINES.  211 

oil,  calomel,  or,  in  fact,  anything  that  the  normal  stomach  will  tolerate, 
seem  to  be  well  borne.  Generally  in  favorable  cases  peristalsis  becomes 
quickly  reestablished,  and  the  fistula  closes  spontaneously  or  can  be 
closed  by  operation. 

In  abdominal  operations  in  which  the  immediate  necessity  for  the 
establishment  of  a  fistula  does  not  exist,  and  yet  in  which  the  operator 
has  reason  to  fear  that  the  operation  may  later  become  indicated,  it  is 
well  before  closing  the  abdomen  to  determine  the  loop  of  intestine  in 
which  the  opening  can  be  most  advantageously  made.  This  loop  should 
be  fixed  by  the  gauze  packing  in  order  that  it  may  be  readily  accessible 
for  subsequent  manipulation.  Guide  sutures  should  be  inserted  into 
the  bowel  wall  at  the  point  to  be  opened.  These  may  be  taken  out 
without  harm  at  any  time  later  and  the  gauze  removed,  if  it  is  found 
unnecessary  to  incise  the  bowel. 

Postoperative  intestinal  fistula  once  estabhshed  should  be 
looked  upon  more  as  a  mouth  than  an  anus.  It  should  be  used  for 
irrigation  of  the  intestinal  canal,  for  the  nourishment  of  the  patient, 
and  for  the  introduction  of  cathartics.  We  have  often  noticed  that  food 
introduced  into  the  intestinal  canal  through  the  fistula  had  of  itself  a 
stimulating  effect  upon  the  peristalsis. 


CHAPTER  XL 

LAPAROTOMY  AND  OPERATIONS   UPON  THE 

ABDOiMEN. 


CHAPTER  XI. 
LAPAROTOMY  AND  OPERATIONS  UPON  THE  ABDOMEN. 

Postoperative  Treatment  of  Operations  Upon  the  Abdomen. — 

In  all  laparotomies,  whether  the  operation  is  to  be  on  the  stomach  and 
intestinal  tract,  uterus,  or  ovaries,  the  stomach  and  intestines  must  be 
emptied,  the  former  by  means  of  lavage,  the  latter  by  laxatives.  As 
laxatives  increase  the  number  of  bacteria,  they  should  not  be  given 
later  than  two  days  before  the  operation.  The  food  must  be  such  as 
will  not  result  in  the  formation  of  fecal  matter.  Soups,  vegetable  or 
animal,  gruels,  but  no  milk,  with  an  abundance  of  fluids,  are  the  usual 
routine.  Two  days  before  the  operation  betanaphthol  bismuth  or 
acetozone  should  be  given,  to  limit  as  far  as  possible  the  fermentative 
changes  in  the  intestinal  contents.  When  the  diet  is  very  hmited, 
opium  should  be  given. 

Immediately  following  all  laparotomies,  and  usually  before  the  pa- 
tient is  removed  from  the  operating  table,  if  there  has  been  any  con- 
siderable loss  of  blood,  or  if  the  patient  be  apparently  delicate  in  nature 
or  of  neurotic  temperament,  a  high  rectal  enema  of  normal  salt  solution 
should  be  administered,  the  solution  being  at  a  temperature  of  io8° 
to  iio°  F.  If  there  seems  to  be  a  lack  of  tone  or  a  general  depressed 
condition,  hypodermatic  injections  of  nitroglycerin,  strychnin,  and  digi- 
talin  should  be  promptly  given. 

Gruzdeff  has  long  advocated  copious  flushing  of  the  abdominal 
cavity  with  saline  solution  before  closing  it  after  a  laparotomy.  In 
28  cases  in  which  the  abdomen  was  treated  by  the  dry  method  there 
were  3  deaths,  while  only  one  patient  died  in  the  72  cases  in  which  he 
followed  his  method  of  irrigation,  and  this  fatality  was  due  to  other 
causes.  He  prefers  Locke's  solution  for  the  purpose,  as  more  nearly 
approximating  the  composition  of  the  blood-plasma,  and  pours  it  into 
the  abdomen  three  or  four  times,  swabbing  out  the  cavity  each  time 
with  gauze  sponges,  and  finally  leaving  a  large  amount  in  the  abdomen 
after  it  is  sutured.  He  thinks  by  this  means  the  abdominal  cavity  is 
not  only  cleaned,  but  the  germs  that  may  have  found  their  way  in  dur- 

215 


2l6  POSTOPERATIVE    TREATMENT. 

ing  the  operation  are  washed  out  and  the  phagocytes  are  stimulated 
to  more  energetic  action.  A  still  further  advantage  is  that  the  pressure 
in  the  abdomen  is  maintained  by  the  fluid  left  behind,  and  it  does  not 
tend  to  collapse  after  the  removal  of  large  tumors.  If  symptoms  of 
pronounced  shock  are  present,  the  treatment  should  be  energetic,  as 
heretofore  described.  (See  page  83.)  Patients  who  are  allowed  to 
go  for  several  hours  with  a  subnormal  temperature  and  high  pulse  are 
with  great  difficulty  restored.  (Martin.)  In  all  aseptic  cases  the  wound 
itself  requires  little  or  no  attention  for  several  days,  and  the  dressings 
about  the  wound  should  not  be  disturbed  unless  symptoms  of  infec- 
tion supervene,  as  announced  by  rising  temperature,  high  pulse-rate, 
and  general  restlessness.  After  nine  to  fourteen  days  the  wound  should 
be  carefully  examined  and  the  stitches  removed,  after  which  small 
strips  of  sterile  adhesive  plaster  should  be  applied  to  support  and  pre- 
vent spreading  of  the  scar. 

Care  of  the  Bowels. — If  flatus  has  not  passed  freely  from  the  rec- 
tum in  twelve  hours  by  the  simple  employment  of  a  rectal  tube,  a  rec- 
tal enema  of  one  ounce  of  magnesium  sulfate,  two  ounces  of  glycerin, 
and  three  ounces  of  water  should  be  given.  If  there  is  no  bowel  move- 
ment or  if  the  retention  of  flatus  is  obdurate,  one-half  grain  doses  of 
calomel  with  or  without  sodium  bicarbonate  should  be  given  every  two 
hours  until  four  to  six  doses  are  given,  or  until  gas  passes.  If  necessary, 
the  calomel  may  be  given  alternately  with  dram  doses  of  Rochelle  salts, 
magnesium  citrate  or  sulfate,  in  an  ounce  of  water.  If  the  stomach 
is  very  much  irritated  and  will  not  tolerate  calomel,  after  lavage  with  a 
solution  of  boric  acid  and  before  the  stomach-tube  is  removed  one  ounce 
.of  castor  oil  should  be  administered.  The  cases  are  very  few  that  will 
not  yield  under  these  remedies.  For  more  persistent  cases  or  post- 
operative complications  the  reader  is  referred  to  matter  as  heretofore 
described  under  special  headings. 

Drainage. — When  the  glass  drainage-tube  is  allowed  to  remain 
in  the  abdominal  wound,  it  should  be  gently  emptied  in  one  hour  by  a 
syringe  with  a  long  rubber  nozle.  If  the  fluid  is  more  than  two  or 
three  drams,  it  should  be  dressed  again  in  an  hour,  or  if  the  fluid  is 
less  than  a  dram,  the  intervals  between  dressings  should  be  increased. 
The  tube  is  usually  removed  in  twenty-four  hours.  If,  however,  after 
this  time  drainage  seems  necessary,  a  small  piece  of  sterilized  gauze 
may  be  inserted  in  place  of  the  glass  tube,  and  allowed  to  remain  six 
to  twelve  hours,  after  which  the  wound  is  closed  by  ordinary  sterile 


LAPAROTOMY   AND   OPERATIONS    UPON  THE  ABDOMEN.  21 7 

adhesive  strips.  If  capillary  gauze  drainage  has  been  employed  in- 
stead of  a  glass  tube,  the  protruding  gauze  should  be  abundantly  cov- 
ered with  a  pad  of  loose,  fluffy  gauze,  and  this  should  be  changed  as 
often  as  it  becomes  saturated  with  fluid.  If  all  drainage  ceases  in  twelve 
to  twenty-four  hours  as  indicated  by  dry  dressings,  the  gauze  packing, 
if  loose,  may  be  removed.  However,  if  drainage  is  free  and  the  patient 
is  normal  in  condition,  the  gauze  may  remain  forty-eight  to  sixty  hours, 
and  after  its  removal  a  loose  gauze  packing  should  be  placed  over  the 
wound. 

Urine. — The  patient  should  always  be  urged  to  pass  urine  volun- 
tarily and  the  catheter  should  not  be  resorted  to  unless  absolutely  un- 
avoidable. 

General  Remarks. — So  soon  as  possible  after  anesthesia  hot  water 
or  hot  tea  in  teaspoonful  doses  may  be  given  as  often  as  every  fifteen 
minutes  if  the  patient  is  extremely  thirsty.  If  the  stomach  tolerates 
this,  the  quantity  is  increased  to  half  an  ounce  every  half-hour.  When 
the  patient  cannot  take  hot  water  and  complains  of  intense  thirst,  the 
nurse  is  instructed  to  let  him  rinse  the  mouth  with  cold  water.  After 
twelve  hours,  if  the  patient's  condition  is  such  as  to  demand  nourish- 
ment, peptonoids  or  peptonized  milk  may  be  substituted;  later,  fluid 
nourishment,  bouillon,  broth,  or  thin  gruel,  may  be  substituted,  so  that 
by  the  third  or  fourth  day  the  patient  will  be  able  to  take  the  extracts 
of  beef,  shellfish  broth,  etc.  Orange-juice  and  the  juices  of  other  ripe 
fruits  are  often  greatly  relished,  and  may  be  used  in  small  and  oft- 
repeated  quantities.  If  stimulants  are  required,  whisky  is  the  best, 
or  champagne  may  be  used.  If  patients  are  unable  to  retain  sufficient 
food  by  the  stomach  to  nourish  them  properly,  nutrient  enemas  as 
heretofore  described  should  be  resorted  to.  Uncomplicated  laparotomy 
cases  after  the  tenth  day  are  permitted  to  sit  up  in  bed  with  back-rests, 
and  after  the  twenty-first  day  are  allowed  to  be  seated  in  chairs,  but 
are  not  allowed  to  leave  the  hospital  before  the  twenty-eighth  to  the 
fortieth  day.     (Martin.) 

Laparotomy  for  Septic  Conditions. — The  surgeon  frequently 
finds  himself  forced  to  operate  after  dift'use  peritonitis  from  ruptured 
pus-tubes,  appendix,  or  other  sources  of  infection,  and  these  cases 
should  be  classed  by  themselves,  and  so  far  as  after-treatment  is  con- 
cerned, they  belong  to  a  different  category  from  aseptic  cases.  How 
best  to  proceed  under  the  circumstances  to  save  an  apparently  hopeless 
case  is  tersely  stated  by  Kocher  as  follows:   "x\s  soon  as  the  abdommal 


2l'8  POSTOPERATIVE    TREATMENT. 

cavity  has  been  opened,  the  heakhy  regions  of  the  abdomen  should 
be  shut  off  from  the  diseased  parts  on  which  the  operation  is  to  be  car- 
ried out.  This  should  be  done  by  packing  with  gauze.  The  intro- 
duction, through  a  sufficiently  large  external  wound,  of  hot,  sterile, 
soft  gauze  compresses,  wrung  out  of  an  8  percent  salt  solution,  so  as 
to  shut  off  the  field  of  operation,  insures  against  the  harm  which  re- 
sults, especially  in  septic  cases,  from  the  escape  of  gastrointestinal 
contents,  bile,  urine,  or  infective  inflammatory  products. 

"Avoid  any  antiseptic  and  any  possibility  of  injury  to  the  peri- 
toneum by  cooling  and  evaporation.  No  small  praise  is  due  to  Tavel 
and  his  pupils  for  having  demonstrated  experimentally  the  nature  of 
this  deleterious  action,  and  for  having  rendered  its  avoidance  possible. 
On  the  basis  of  their  researches  we  were  probably  the  first  to  employ 
(chiefly  in  laparotomies)  only  physiologic  salt  solution  at  the  body- 
temperature  and  to  keep  all  exposed  peritoneal  surfaces  constantly 
moist  and  warm  by  irrigation,  or  by  applying  compresses  and  gutta- 
percha tissue  over  them.  Complete  removal  of  every  source  of  infec- 
tion and  drainage  of  infected  areas,  combined  with  their  isolation  by 
tampons  in  the  form  of  gauze  strips  impregnated  with  a  fixed  antisep- 
tic, as  recommended  by  Mikulicz,  is  necessary.  As  iodoform  has 
such  a  toxic  action  on  the  peritoneum,  xeroform  or  some  other  non- 
toxic antiseptic  should  be  preferred. 

"Prevention  of  any  collection  of  blood  or  effusion  into  the  wound 
by  most  careful  arrest  of  hemorrhage,  no  matter  how  long  the  time 
required  to  effect  this,  and  by  careful  suture  of  every  injured  surface 
of  the  peritoneum,  is  required.  This  is  a  most  important  point,  and 
it  was  only  when  attention  was  paid  to  it  that  the  intraperitoneal  treat- 
ment of  a  uterine  stump  was  ^rendered  safe. 

"Tietze  showed  by  his  excellent  experiments  that  the  omentum 
could  be  safely  employed  for  covering  over  necrotic  areas  in  the  stom- 
ach or  intestinal  wall.  Braun  and  Bennet  even  closed  defects  in  the 
stomach  with  omentum  only,  which  formed  firm  adhesions  to  the  sur- 
rounding serous  membrane.  The  inner  surface  of  the  omentum  grad- 
ually becomes  covered  over  with  epithelium  which  grows  in  from  the 
edges  of  the  opening.  Careful  suture  of  every  cut  or  tear  in  the  peri- 
toneum, and  complete  closure  of  the  main  wound  in  every  case  when 
there  is  no  question  of  draining  away  infective  fluids,  is  essential." 

Position  of  Incisions.— The  only  incisions  in  the  abdomen  which 
can  be  regarded  as  normal  are  the  median,  the  transverse  in  the  upper 


LAPAROTOMY    AND    OPERATIONS    UPON    THK    ABDOMEN.  219 

part  of  the  abdomen,  and  the  oblique  incision  yjassing  from  above 
downward  and  inward  in  the  lower  part  of  the  abdomen,  because  these 
incisions  do  not  damage  the  muscles  of  the  abdominal  wall  through 
their  nerve-supply,  and  are  in  accordance  with  the  principles  which 
have  been  already  laid  down  for  all  the  normal  incisions  of  the  body. 
The  above  normal  incisions  can  be  very  well  used  in  combination,  as, 
for  instance,  in  splenectomy,  or  for  carcinoma  of  the  lowest  part  of  the 
sigmoid  flexure,  when  to  the  median  incision  a  transverse  incision  may 
be  added,  varying  in  length  according  to  the  requirements.  Assmy, 
at  Czerny's  instigation,  showed  that  the  longitudinal  incisions  through 
the  middle  of  the  rectus,  which  are  preferred  by  many  surgeons,  cause 
atrophy  of  the  median  portion  of  the  rectus  if  its  motor  nerves  are  inter- 
fered with. 

Laparotomy  in  Cases  of  Peritonitis. — When  an  exudate  which 
can  be  demonstrated  clinically  has  formed  in  the  peritoneal  cavity, 
the  only  certain  way  of  preventing  extension  of  the  inflammatory  effu- 
sion is  by  early  operation.  When  exploring  the  deeper  parts  in  such 
conditions,  it  is  quite  unnecessary  to  use  any  other  than  the  normal 
incision  with  splitting  of  the  muscles. 

According  to  McBurney's  method,  all  circumscribed  abscesses, 
both  those  with  fluid  contents  and  those  in  which  there  is  merely  a  free 
inflammatory  exudate,  can  in  this  way  be  thoroughly  evacuated  and 
drained  through  a  small  incision.  Difficulty  is  first  apparent  in  the 
treatment  of  peritonitis  wh'en  numerous  small  or  large  abscesses  sur- 
rounded by  fibrous  adhesions  have  formed  in  different  parts  of  the 
peritoneal  cavity.  Many  cases  have  been  recorded  of  satisfactory  re- 
sults in  so-called  diffuse  peritonitis,  which,  however,  were  not  diffuse  in 
the  sense  that  the  whole  peritoneal  cavity  up  to  the  diaphragm  was 
involved,  but  which  represented  merely  encapsulated  inflammations 
occupying  a  large  area  of  the  peritoneum.  There  is  only  one  certain 
means  of  dealing  with  such  diffuse  forms  with  numerous  encapsulated 
foci  of  infection,  and  that  is  by  prophylactic  treatment.  A  circum- 
scribed abscess  may  lead  to  multiple  abscess-formation  either  by  the 
spread  of  the  infective  material  or  by  perforation,  or,  a  priori,  diff'use 
peritonitis  with  fluid  exudate  may  lead  to  multiple  suppurative  areas 
by  the  pouring  out  of  fibrin  and  the  formation  of  adhesions.  The  only 
way  to  prevent  this  extension  is  to  treat  every  attack  of  inflammation 
at  its  commencement  on  surgical  principles,  /.  e.,  to  open  and  remove 
the  infective  material.     In  this  respect  the  advocates  of  immediate 


220  POSTOPERATIVE    TREATMENT. 

operation  in  early  cases  of  perforated  appendicitis  are  undoubtedly 
right,  as  a  definite  percentage  of  the  cases  in  which  expectant  treatment 
is  employed  in  preference  to  immediate  operation  must  be  lost  from 
peritonitis.  When  an  incision  is  at  once  made,  as  advocated  by  Ber- 
nays,  Rehn,  Deaver,  and  others,  and  the  source  of  infection  removed, 
although  death  cannot  be  avoided  in  every  case,  yet,  as  Bernays  has 
proved,  the  results,  if  all  the  cases  be  taken  into  account,  are  better  than 
those  where  expectant  treatment  is  employed. 

In  peritonitis  which  is  diffuse  from  the  onset,  with  a  fluid  exudate, 
it  is  quite  justifiable,  after  the  cause  has  been  removed,  to  make  a 
median  incision  and  to  irrigate  the  peritoneal  cavity  thoroughly  with 
physiologic  salt  solution  at  the  body-temperature,  for  as  long  a  period 
as  may  be  required.  For  diffuse  peritonitis  with  multiple  encapsulated 
abscesses,  not  only  between  the  intestinal  coils,  but  also  between  the 
liver,  spleen,  and  diaphragm,  a  long  laparotomy  incision  is  indicated, 
so  that  free  access  may  be  gained  to  all  abscesses.  But  such  a  long 
incision  is  attended  with  danger  from  shock,  the  result  of  injury  to  the 
hyperesthetic  peritoneum;  it  reflexly  inhibits  or  paralyzes  the  vaso- 
motor center,  and,  by  a  direct  action  on  the  abdominal  vessels,  increases 
the  venous  hyperemia  in  the  abdomen,  and  with  it  secondary  cerebral 
anemia. 

In  severe  cases  it  often  becomes  necessary  to  empty  the  intestines 
by  washing  them  out  thoroughly  through  an  opening  above  and  below 
in  order  to  prevent  absorption  of  toxic  products  from  the  intestines, 
and  to  keep  them  empty  by  the  administration  of  magnesium  sulfate. 
Further,  after  the  operation,  hyperemia  of  the  abdominal  organs  should 
be  reduced  as  much  as  possible  by  proper  posturing  of  the  patient, 
combined  with  the  application  of  ice  and  compression  to  the  abdomen. 
A  matter  of  great  importance  in  the  treatment  of  peritonitis  is  to  drain 
off  all  inflammatory  products  and  infective  material.  For  this  purpose 
the  insertion  of  one  drainage-tube  is  not  sufficient.  Each  area  of  sup- 
puration must  be  opened  and  drained.  If  this  is  done,  it  will  be  found 
unnecessary  to  irrigate  in  cases  of  dift'use  multiple  collections  of  pus, 
and  the  resulting  shock  is  much  less. 

Postoperative  Laparotomy  for  Peritoneal  or  Intestinal  Adhe- 
sions.—Lauenstein  emphasized  the  good  results  which  can  often  be 
obtained  in  cases  of  severe  pain  and  spasms  in  the  region  of  the  diges- 
tive tract  by  opening  the  abdomen  and  simply  separating  adhesions  which 
fix  the  viscera  to  some  particular  spot  on  the  abdominal  wall,  or  which 


LAPAROTOMY    AND    OPERATIONS    UPON    THE    ABDOMEN.  221 

link  or  bind  them  together.  The  importanre  of  this  condition  has  not 
been  fully  appreciated.  The  results  of  such  an  operation  are  often 
striking  and  immediate,  and  relief  may  be  given  from  suffering  which 
has  existed  for  years. 

A  short  time  ago  the  author  operated  on  a  patient  who  was  suffer- 
ing from  repeated  attacks  of  acute  abdominal  pain  attended  with  symp- 
toms of  collapse,  so  much  so  that  the  question  of  perforation  was  con- 
sidered, more  especially  as  there  was  a  history  of  previous  dysenter}'. 
Laparotomy  was  performed,  and  strong  adhesions  binding  a  portion 
of  the  small  intestines  to  the  lateral  aspect  of  the  abdominal  wall  were 
discovered  and  divided.  The  whole  of  the  symptoms  disappeared. 
The  agony  had  been  so  intense  that  the  patient  dreaded  taking  food,  and 
in  consequence  was  very  much  emaciated.     Recovery  was  complete. 

No  directions  suitable  for  every  case  can  be  given.  The  adhesions 
must  be  completely  divided  in  order  to  insure  perfect  freedom  of  move- 
ment of  the  viscera,  and,  where  possible,  large  raw  areas  must  be  cov- 
ered with  healthy  peritoneum  or  omentum.  If  it  is  correct  that  silk 
ligatures  become  permanent  foreign  bodies,  and,  therefore,  liable  to 
cause  adhesions,  preference  must  be  given  to  catgut,  which  is  easily 
absorbed. 

Method  of  Preventing  Postoperative  Adhesions  of  Intestines. — 
Charles  Cargile,  of  Bentonville,  Ark.,  has  made  use  of  serous  mem- 
brane for  the  purpose  of  preventing  intestinal  or  abdominal  adhesions 
following  laparotomy.  After  a  somewhat  extended  experience  the 
Cargile  membrane,  as  it  is  called,  received  the  indorsements  of  Robert 
T.  Morris,  of  New  York,  and  John  B.  Deaver,  of  Philadelphia.  At 
the  suggestion  of  these  operators  this  membrane  has  been  prepared 
and  made  accessible  to  the  profession  »through  Johnson  &  Johnson. 
It  is  put  up  under  the  name  of  "Cargile  Membrane,"  packed  in  strips 
about  4  by  6  inches,  each  piece  sterilized  and  inclosed  in  a  double  en- 
velop. The  membrane  is  very  soft,  smooth,  pliable,  and  transparent, 
producing  no  irritation,  and  adapts  itself  closely  to  the  surfaces  ap- 
plied to.  It  is  intended  to  act  as  a  protective  dressing  to  the  denuded 
surfaces.  It  is  nonirritating  and  is  absorbed  in  from  two  to  three  weeks. 
More  recently  A.  B.  Craig,  of  Philadelphia,  carried  out  a  series  of  ex- 
periments on  dogs,  using  Cargile  membrane  in  an  attempt  to  prevent 
peritoneal  adhesions.  After  careful  study  and  the  reopening  of  abdo- 
mens at  various  intervals,  he  is  of  opinion  that  the  membrane,  for  this 
purpose,  is  practically  valueless. 


222  POSTOPERATIVE    TREATMENT. 

The  author  has  used  in  operating  for  umbilical  hernia,  where  in- 
testinal adhesions  were  most  pronounced,  a  thin  layer  of  carefully  ster- 
ilized goldbeater's  skin,  which  answers  the  purpose  most  admirably. 

Operations  on  the  Gastrointestinal  Canal. — Whenever  the  ali- 
mentary canal  is  opened,  septic  influences  have  to  be  combated,  for 
the  gastrointestinal  contents,  under  normal  conditions,  harbor  a  far 
greater  number  and  variety  of  bacteria  than  does  the  skin.  Our  first 
care  must,  therefore,  be  to  endeavor  to  limit  the  risk  of  infection  to  as 
small  an  area  as  possible.  The  means  by  which  we  seek  to  avoid  these 
contingencies  are  various,  and  cannot  be  the  same  for  every  case. 
The  method  of  preventing  a  spread  of  infection  by  means  of  compresses 
has  been  considered  under  the  general  remarks  on  laparotomy.  But 
the  protection  of  the  immediate  neighborhood  from  contamination  de- 
pends chiefly  upon  whether  the  organ  which  has  been  opened  can  be 
entirely  closed,  as,  for  example,  in  Billroth's  second  method  of  pylorec- 
tomy,  and  in  Kocher's  method  of  performing  resection  of  the  pylorus, 
in  which  the  stomach  is  completely  closed  after  the  removal  of  the  neo- 
plasm; or  whether  the  opening  which  has  been  made  has  to  be  joined 
to  some  other  part  of  the  gut  in  order  to  form  an  anastomosis,  as  in 
gastroenterostomy  and  the  various  enteroanastomoses. 

In  all  cases,  and  without  exception  in  those  in  which  the  mucous 
membrane  of  the  gut  has  been  exposed,  a  thorough  cleansing  of  the 
surrounding  parts  must  be  effected  after  the  suture  including  all  the 
layers  has  been  introduced,  and  before  the  serous  suture  is  apphed, 
and  if  necessary,  soiled  swabs  used  in  shutting  off  the  field  of  operation 
must  be  replaced  by  fresh  ones.  The  certainty  of  closure  of  gut  or 
stomach  always  depends  on  the  union  of  the  peritoneum  of  both  ends 
of  the  gut,  but  exact  apposition  of  the  mucous  and  muscular  coats  is 
worthy  of  more  attention  than  has  for  some  time  been  paid  to  it.  If 
these  layers  are  properly  united,  function  is  more  quickly  restored,  and 
what  is  far  more  important,  necrosis  of  the  margin  of  the  wound  to- 
ward the  lumen  of  the  gut  is  avoided.  Such  necrosis  rarely,  but  never- 
theless occasionally,  gives  rise  to  phlegmonous  infiltration  of  stomach 
wall;  while  more  frequently  it  leads  to  formation  of  small  foci  of  in- 
fection and  metastatic  inflammation,  pneumonia,  etc. 

AFTER-TREATMENT  OF  ABDOMINAL  SECTION. 

Method  of  Sir  Frederick  Treves. — General  Measures. — The 
patient  must  lie  absolutely  upon  the  back,  and  the  knees  may  be  kept  a 


LAPAROTOMY    AND    OPKRATIONS    UPON   THE    ABDOMKN'.  223 

little  llexcd  by  placing  a  j^illow  beneath  them.  /\  large  cradle  is  placed 
over  the  trunk.  It  protects  the  abdomen  from  the-  pressure  of  the  bed- 
clothes, and  helps  to  ventilate  the  bed.  The  patient's  body  is  covered 
by  a  blanket,  which  is  placed  beneath  the  cradle  and  in  direct  contact 
with  the  trunk.  The  rest  of  the  bed-clothes  are  in  two  sets,  so  folded 
as  to  meet  transversely  in  the  center  of  the  bed.  They  are  [jlaced  over 
or  outside  the  cradle,  overlapping  at  its  summit.  This  arrangement 
permits  of  the  wound  being  inspected  and  dressed  and  enemas,  etc., 
given  without  disturbing  the  bed-clothes  that  cover  either  the  uj;per  part 
of  the  body  or  the  lower  limbs. 

The  bed  should  be  well  warmed  with  hot  bottles  before  the  patient 
is  placed  in  it,  and  hot  bottles  may  be  kept  in  contact  with  the  feet  and 
thorax  for  some  time  after  the  operation.  The  patient's  movements 
should  be  restrained  while  consciousness  is  returning,  and  the  nurse 
may  support  the  wound  with  the  hands  during  the  first  attack  of  vomit- 
ing. The  less  the  patient  is  interfered  with  during  the  first  twenty- 
four  hours  after  the  operation,  the  better.  Morphin  should  be  avoided 
whenever  it  is  possible,  and  should  never  be  given  as  a  matter  of  rou- 
tine. One-sixth  of  a  grain  is  sufficient  at  a  time.  One  injection  only 
will  probably  be  found  to  be  sufficient. 

The  less  taken  by  the  mouth  during  the  first  twenty-four  hours, 
the  better.  Nothing  whatever  need  be  given  by  the  mouth  for  the  first 
nine  hours.  The  patient  is  then  allowed  hot  water  or  hot  weak  tea 
in  doses  of  half  an  ounce  every  half-hour  or  so.  Ice  is  to  be  absolutely 
condemned.  The  reckless  and  immoderate  sucking  and  bolting  of  lumps 
of  ice,  which  are  encouraged  by  the  nurse  who  believes  a  patient  is  doing 
badly  who  is  not  constantly  swallowing  something,  is  most  pernicious. 
The  stomach  becomes  filled  with  cold  fluid,  and  a  sense  of  great  faint- 
ness  and  discomfort  persists  until  the  melted  ice  is  ejected  by  vomit- 
ing. If  really  distressing  thirst  is  experienced  during  the  first  twenty- 
four  hours,  it  is  best  relieved  by  an  enema  of  warm  water.  No  other 
form  of  rectal  injection  should  be  allowed.  During  the  second  day  the 
patient  may  take  hot  tea  or  barley-water  in  small  quantities,  provided 
such  nourishment  does  not  cause  vomiting. 

A  catheter  should  be  passed  when  required.  It  will  not  be  needed 
during  the  first  twenty-four  hours,  and  the  sooner  the  patient  can  dis- 
continue its  use,  the  better.  The  practice  of  passing  a  catheter  by 
routine  once  in  so  many  hours  is  most  decidedly  to  be  condemned. 
As  a  rule,  very  little  urine  enters  the  bladder  during  the  first  twenty- 


224  POSTOPERATIVE    TREATMENT, 

four  hours  after  operation.  Nutrient  enemas  are  not  needed  except 
in  very  unusual  cases  attended  with  persistent  vomiting.  In  a  case  that 
is  doing  well  the  diet  from  the  third  to  the  fourth  day  may  consist  of 
tea  and  toast,  peptonized  milk,  malted  foods,  etc.  Meat  extracts  and 
meat  jellies  of  all  kinds  are  to  be  avoided.  Milk  is  not  usually  well 
borne,  and  leads  to  the  formation  of  scybala,  while  the  indiscreet  per- 
severance in  a  slop  diet  often  causes  nausea  and  flatulence.  What 
food  is  given  should  be  given  often  and  in  small  quantities.  A  little 
fish  may  be  given  on  the  fourth  day,  and  meat  on  the  seventh.  Through- 
out the  progress  of  an  abdominal  case  patent  foods  are  as  much  to  be 
avoided  as  patent  medicines. 

The  bowels  may  possibly  act  spontaneously.  As  a  rule,  however, 
they  do  not.  In  such  circumstances  an  aperient  followed  by  an  enema 
should  be  administered  on  the  third  or  fourth  day.  The  aperient 
selected  should  be  that  which  the  patient  is  accustomed  to  take.  Cas- 
tor oil  is  much  to  be  commended.  The  enema  is  most  important  for 
the  purpose  of  clearing  out  the  lower  bowel.  It  may  be  repeated  if 
there  be  any  evidence  that  the  rectum  is  not  well  emptied.  The  injec- 
tion need  not  be  copious ;  and  in  cases  in  which  extensive  pelvic  adhe- 
sions have  been  dealt  with,  even  small. enemas  often  cause  distress. 

Flatulence  or  distention  of  the  belly  is  frequently  complained  of 
at  an  early  period  after  the  operation.  It  may  to  some  extent  be  re- 
heved  by  the  use  of  the  "rectum  tube."  This  consists  in  the  vaginal 
pipe  of  an  ordinary  Higginson's  syringe  or  a  large  soft-rubber  catheter. 
The  tube  is  passed  about  two  or  three  inches  into  the  rectum,  and  may 
be  left  there  for  ten  or  fifteen  minutes,  or  so  long  as  it  appears  to  afford 
the  patient  relief.  A  small  soap-dish  must  be  placed  under  the  free 
end  of  the  tube,  to  receive  any  fecal  matter  that  may  escape.  In  these 
cases  of  flatulent  distention  minute  doses  of  a  carminative,  notably 
of  one  of  the  aromatic  oils,  often  have  a  very  excellent  effect,  and  the 
same  may  be  said  in  a  lesser  degree  of  sal  volatile  and  spirits  of  chloro- 
form. A  hypodermatic  injection  of  strychnin  (^V  grain)  is  sometimes 
useful  in  overcoming  intestinal  distention.  But  probably  the  simplest 
and  most  efficacious  measure  is  to  turn  the  patient  on  the  side  for  a 
time.  This  can  often  be  done  with  safety,  and  affords  relief  to  the  back- 
ache so  frequently  complained  of. 

Now  and  then  it  will  be  found  that  about  or  before  the  seventh 
day  after  the  operation — often  about  the  fourth  or  fifth — the  abdomen 
is  distended,  the  tongue  is  coated  and  foul,  the  belly  is  tender,  and 


LAPAROTOMY   AND   OPERATIONS   UPON  THE   ABDOMEN.  225 

complaint  is  made  of  the  tightness  of  the  binder,  while  there  may  be  a 
little  vomiting  or  nausea.  The  temperature  remains  normal,  the  res- 
piration unaffected,  the  complexion  unaltered,  and  the  pulse  and  gen- 
eral condition  good.  The  symptoms  in  such  a  case  may  depend  upon 
the  fact  that  the  bowels  had  not  been  well  evacuated  before  the  opera- 
tion, or  the  intestine  may  have  been  partially  paralyzed  by  too  much 
opium,  or  the  diet  since  the  operation  may  have  been  such  as  to  lead 
to  tympanitic  distention.  The  lavish  use  of  meat  extracts  or  concen- 
trated meat  preparations  is  very  likely  to  be  followed  by  great  disten- 
tion due  to  decomposition.  The  patient  who  presents  these  symptoms  is 
often  greatly  relieved  by  a  saline  or  .other  aperient.  The  bowel  is  well 
cleared  out,  and  the  sickness,  pain,  and  distention  vanish.  It  is  pos- 
sible that  cases  of  this  character,  relieved  in  the  manner  indicated, 
may  have  been  described  as  examples  of  acute  peritonitis  treated  by 
saline  aperients. 

The  graver  complications  after  abdominal  section — among  which 
may  be  mentioned  internal  hemorrhage,  peritonitis,  septicemia,  intes- 
tinal obstruction,  fecal  fistula,  thrombosis,  parotitis,  and  pulmonary 
embolism — must  be  treated  according  to  the  measures  advised  in  the 
treatises  on  surgery. 

After-treatment  OF  THE  WouND. — The  dressing  may  be  removed 
on  the  fourth  day.  The  wound  should  be  kept  dry.  It  needs  no  wash- 
ing, nor  to  be  touched,  with  anything  moist.  The  dried  iodoform  pow- 
der is  picked  off  with  sterilized  forceps,  and  fresh  iodoform  is  apphed 
under  a  new  dry  dressing.  The  binder  and  thigh  pieces  are  once  more 
adjusted.  The  sutures  should,  as  a  rule,  be  left  in  for  ten,  twelve,  or 
even  fifteen  days.  In  other  words,  a  firm  scar  should  have  time  to 
form  before  they  are  removed.  The  retention  of  the  stitches  will  enable 
the  operator  to  dispense  with  the  subsequent  use  of  strapping. 

Throughout  the  whole  period  of  convalescence  the  binder  should 
be  retained,  and  be  always  carefully  applied.  In  cases  in  which  the 
wound  has  become  infected  and  fails  to  heal,  or  in  which  it  has  burst 
open  after  the  removal  of  the  sutures  by  reason  of  violent  expiratory 
movements  on  the  part  of  the  patient,  or  in  which  the  incision  has  been 
deliberately  opened  up  by  the  surgeon,  the  margins  should  be  kept 
well  adjusted  by  means  of  strapping,  which  in  such  cases  will  require 
to  be  reapplied  once,  or  possibly  twice,  in  the  twenty-four  hours. 

For  the  first  fortnight  after  the  operation  the  patient  should  lie 

upon  the  back  and  be  kept  as  still  as  possible.     At  the  end  of  this  tmie 
16 


226  POSTOPERATIVE    TREATMENT. 

he  or  she  may  be  allowed  to  be  a  little  raised  in  bed,  or  to  lie  upon  one 
side  while  the  back  is  Well  supported  with  pillows.  Between  the  third 
and  the  fourth  week  the  patient  may  be  allowed  to  get  up.  Such  are 
the  times  which  may  be  observed  in  an  ordinary  case  of  average  sever- 
ity. In  a  large  proportion  of  instances  it  is  well  that  the  patient  should 
remain  in  bed  one  month,  whereas  in  the  simplest  exploratory  opera- 
tions the  patient  may  be  allowed  up  on  the  eighteenth  day,  or  even 
before.  Some  surgeons  will  allow  a  woman  convalescent  from  ovariot- 
omy to  leave  the  hospital  on  the  eighteenth  day.  It  is  well,  probably, 
to  err  in  the  direction  of  encouraging  a  longer  period  of  rest  after  these 
operations.  Some  complications,  notably  that  of  phlegmasia,  appear 
to  be  encouraged  by  too  early  movement. 

In  a  few  cases  before  the  patient  leaves  the  surgeon's  care  an  ab- 
dominal belt  should  be  ordered.  This  should  be  largely  composed  of 
elastic,  and  may  be  worn  from  three  to  six  months.  After  the  simplest 
procedures  a  flannel  binder  is  all  that  is  necessary;  but  in  cases  of  pen- 
dulous abdomen,  and  in  instances  in  which  the  healing  of  the  wound 
has  been  imperfect  or  interrupted,  or  a  very  large  tumor  has  been  re- 
moved, a  well-made  and  very  carefully  fitted  belt  is  required.  The 
primary  object  of  a  belt  in  these  cases  is  to  assist  the  cicatrix  in  resist- 
ing the  weight  of  the  viscera  and  the  passive  pressure  from  within.  It 
must  be  remembered  that  the  abdominal  wall  is  made  up  of  muscular 
and  aponeurotic  tissues.  It  is  required  that  these  tissues  should 
not  be  weakened.  Like  tissues  elsewhere,  they  atrophy  from  disuse 
and  are  rendered  strong  by  exercise.  The  very  elaborate,  rigid,  and 
heavy  belts  which  are  sometimes  worn  after  abdominal  section,  espe- 
cially after  ovariotomy,  may  possibly  do  harm  by  taking  upon  them- 
selves too  much  of  the  function  of  the  muscles  and  aponeuroses. 

APPENDICECTOMY. 

General  Principles. — Aseptic  operations  or  operations  performed 
after  all  acute  symptoms  of  inflammation  have  subsided  require  the 
same  general  principles  of  after-treatment  as  those  following  ordinary 
laparotomies,  but  if  the  operation  has  been  performed  when  inflam- 
mation or  suppuration  is  present,  the  wound  must  be  treated  after  the 
open  method.  According  to  Kocher,  acute  appendicitis  is  almost  al- 
ways an  exudative  periappendicitis,  generally  the  result  of  perfora- 
tion, and  should  be  treated  accordingly. 


LAPAEOTOMY    AND    OlMvRATIONS    UPON    TFIJO    ABDOMEN.  227 

In  all  operations  for  the  removal  of  the  a};]jenf]ix  when  inflamma- 
tion is  present,  Bernays  places  a  strip  of  5  percent  iodoform  gauze 
around  the  stump  of  the  appendix  and  on  every  piece  of  gut  on  which 
there  is  a  deposit  of  fibrin  or  any  discoloration  or  suppuration.  Thor- 
ough drainage  is  secured  by  means  of  these  strips,  the  important  point 
being  to  connect  each  area  of  injection  with  the  external  wound  by  the 
shortest  possible  route.  After  three  or  four  days  the  gauze  drainage 
strips  are  gradually  withdrawn,  and  if  upon  final  removal  there  is  much 
evidence  of  suppuration,  repacking  may  be  necessary. 

If  the  case  is  one  of  purulent  perityphlitis  or  periappendicitis,  the 
treatment  is  obvious.  The  abscess  must  be  opened,  drained,  and  kept 
thoroughly  evacuated.  When  the  abscess  is  well  defined  and  walled 
off  from  the  peritoneal  cavity,  the  utmost  caution  is  necessary  to  pre- 
vent disturbance  or  destruction  of  the  adhesions.  Frequently  in  spite 
of  gauze  drainage  these  large  abscesses  heal  slowly,  in  which  case  the 
abscess  cavity  should  be  repacked  daily  with  strips  of  iodoform  gauze 
saturated  with  sterile  cosmolin  or  balsam  of  Peru ;  the  former  has  proved 
very  beneficial  in  our  hands.  If  the  abscess  is  complicated  by  fecal 
fistula,  this  method  of  repacking  daily  will  ordinarily  sufiice  to  bring 
about  a  cure  in  three  or  four  weeks.  If,  however,  the  fecal  fistula  is 
large  and  the  patient  is  declining  in  health,  to  shorten  the  period  of 
convalescence,  and  render  recovery  more  probable,  after  gentle  but 
thorough  irrigation  with  normal  salt  solution  of  the  abscess-cavity  a 
radical  operation  for  the  removal  of  the  appendix  should  be  performed 
exactly  as  during  the  acute  stage.  A  fresh  incision  is  made  quite  apart 
from  the  one  communicating  with  the  abscess-cavity  and  as  far  removed 
from  it  as  possible,  i.  e.,  to  the  border  of  the  rectus  muscle.  The  ad- 
hesions are  carefully  broken  down,  the  appendix  isolated  and  brought 
up  into  the  w^ound  together  with  the  cecum  if  necessary,  and  the  appen- 
dix amputated  by  the  usual  method.  The  small  intestine  and  cecum, 
which  may  be  covered  with  lymph,  must  be  carefully  examined  for 
perforations.  The  fresh  abdominal  wound  may  now  be  closed  and 
sealed,  but  the  wound  leading  to  the  abscess-cavity  should  be  treated 
after  the  open  method,  i.  e. ,  packed  with  strips  of  iodoform  gauze  passed 
well  down  to  the  bottom  of  the  cavity.  Glass  or  rubber  tubes,  as  a 
rule,  should  not  be  used.  By  means  of  this  procedure  we  have  seen 
large  fecal  fistulas  and  abscesses  heal  with  comparative  rapidity. 

Multiple  abscesses  following  appendicectomy  are  of  frequent 
occurrence.     They  usually  appear  within  a  week  or  ten  days  follow- 


228  .  POSTOPERATIVE    TREATMENT. 

ing  the  operation,  and  are  known  to  be  present  by  a  sudden  rise  of 
temperature,  with  pain  in  the  region  of  the  wound.  They  may  appear 
subcutaneously  as  a  hard  lump  or  sweUing,  or  may  form  in  the  deeper 
parts  of  the  wound  or  cavity.  Careful  exploration  with  a  probe  will 
usually  reveal  the  seat  of  the  pus,  which  must  be  given  free  exit.  Thor- 
ough exploration  under  anesthesia  may  be  necessary. 

It  frequently  happens  that  a  counteropening  is  necessary  to  secure 
better  drainage,  especially  when  irrigation  is  desirable.  Fig.  66  il- 
lustrates  this   condition,   although,   especially   in  postcecal  abscesses, 


Fig.  66. — Counteropening  to  Secure  Better  Drainage. 

a  counteropening  through  the  posterior  or  lumbar  region  is  more  desir- 
able. 

Immediately  following' all  severe  septic  operations  a  tight  abdom- 
inal bandage  (preferably  broad  adhesive  strips)  should  be  applied, 
to  prevent  distention;  and  lavage  of  the  stomach  should  be  given  be- 
fore the  patient  is  removed  from  the  operating  table.  So  soon  as  pos- 
sible after  anesthesia  the  patient  should  be  allowed  plenty  of  water  to 
drink,  but  no  food  of  any  character  should  be  given  by  the  stomach 
for  from  three  to  four  days.  If  all  food  is  withheld,  morphin  or  opium 
may  safely  be  given,  and  if  peritonitis  is  present,  we  know  of  no  remedy 
more  potent  in  its  quieting  influence  upon  the  nervous  system  or  in 


LAPAROTOMY   AND   OPERATIONS   UPON    TIIK    ABDOMEN.  229 

preserving  the  strength  of  the  patient.  It  likewise  assists  nature  by 
keeping  the  bowels  quiet,  thus  favoring  adhesions  and  resolution. 
The  early  and  indiscriminate  use  of  calomel  or  other  purgatives,  so 
commonly  prescribed  after  all  laparotomies,  is  mentioned  only  to  be 
condemned.  As  a  rule,  no  purgatives  should  be  administered  until 
the  bowels  manifest  a  disposition  to  move  by  the  rumbling  of  gas  or 
other  symptoms.  If  mcteorism  is  present,  it  may  call  for  the  introduc- 
tion of  the  rectal  tube,  or  high  enemas  of  glycerin  may  be  used  as  de- 
scribed on  page  45. 

Ochsner's  method  of  treating  the  more  severe  types  of  appendi- 
citis prior  to  operative  measures  has  met  such  general  approval  that 
I  feel  confident  if  the  same  common-sense  measures  were  applied 
to  the  after-cure  of  severe  septic  cases  the  mortality  would  be  greatly 
lessened;  viz.,  the  prohibition  of  every  kind  of  food  and  cathartics  by 
the  mouth,  and  the  employment  of  gastric  lavage  as  indicated  by  the 
presence  of  nausea,  vomiting,  or  meteorism. 

After-treatment  (Ochsner). — For  the  first  three  or  four  days 
the  patient  should  be  sustained  entirely  by  rectal  feeding,  nutrient 
enemas  being  given  every  four  hours  (concentrated  predigested  food 
in  quantity  not  more  than  four  ounces);  if  the  patient  is  normal  at 
the  end  of  this  time,  a  moderate  amount  of  liquid  nourishment  may  be 
given  by  the  mouth  at  regular  intervals,  but  if  the  patient  is  not  nor- 
mal at  the  end  of  this  time,  the  rectal  enemas  should  be  continued. 
In  case  of  pain  or  restlessness  morphin  can  be  safely  given,  preferably 
by  hypodermatic  injections,  so  long  as  no  food  is  given  by  the  mouth. 

Postoperative  Treatment  of  Appendicectomy  as  Advocated  by- 
Brewer. — In  interval  cases  and  in  early  acute  conditions  when  the 
abdomen  is  tightly  closed  little  postoperative  interference  is  necessary 
if  the  case  progresses  favorably.  Morphin  in  small  doses  may  be  re- 
quired during  the  first  twenty-four  hours  to  relieve  pain.  The  bowels 
should  be  moved  on  the  third  or  fourth  day.  For  this,  small  doses 
of  calomel  should  be  administered,  followed  by  a  saHne  draft,  and  en- 
emas if  necessary. 

If  much  morphin  has  been  used,  there  may  be  considerable  difh- 
culty  in  bringing  about  a  movement,  on  account  of  the  tendency  to 
nausea  which  prevents  the  free  use  of  salts.  In  these  cases  the  fre- 
quent use  of  high  enemas  will  generally  be  successful  if  there  is  no  peri- 
tonitis. If  the  pulse  and  temperature  are  normal,  the  dressing  need 
not  be  chainged  for  six  or  eight  days     Obstinate  vomiting  after  oper- 


230     •  POSTOPERATIVE    TREATMENT. 

ation  can  generally  be  relieved  by  lavage,  followed  by  absolute  rest 
of  the  stomach,  not  even  water  being  allowed.  The  practice  of  giving 
medicines  ■  to  relieve  postoperative  vomiting  is  to  be  condemned,  as 
they  nearly  alwkys  serve  to  aggravate  the  condition.  Continued  pain 
and  vomiting  after  operation  point  to  peritoneal  irritation;  and  if  the 
pulse  and  temperature  are  elevated  and  the  abdominal  tenderness, 
rigidity,  and  distention  are  increased,  there  is  strong  reason  to  suspect 
a  spreading  peritonitis.  In  these  cases  the  wound  should  be  reopened 
under  anesthesia  and  the  peritonitis  treated  as  indicated  above.  In 
acute  cases  in  which  drainage  is  employed,  the  wound  should  be  in- 
spected frequently  and  the  outside  dressings  changed  as  often  as  they 
become  saturated  with  the  wound  secretions.  If  the  temperature  and 
pulse  remain  elevated,  and  if  tenderness  and  rigidity  are  present,  the 
drains  should  be  removed  and  any  retained  pus  evacuated.  Digital 
exploration  of  the  wound  with  the  gloved  hand  will  often  enable  the 
surgeon  to  recognize  a  collection  of  pus  by  the  induration,  which  may 
not  be  apparent  on  superficial  abdominal  palpation.  Such  deep-seated 
collections  of  pus  are  often  drained  best  by  rubber  tubes  until  the  acute- 
ness  of  the  symptoms  has  subsided.  As  soon  as  the  sinuses  are  reason- 
ably clear  and  granulations  appear,  further  packing  is  unnecessary 
and  only  delays  recovery. 

In  the  treatment  of  a  generalized  peritonitis  the  chief  indication  is 
to  combat  sepsis.  After  the  primary  focus  of  infection  has  been  re- 
moved and  provision  made  for  drainage,  elimination  should  be  favored 
by  the  action  of  the  bowels,  the  kidneys,  and  the  skin.  Calomel  should 
be  administered  as  soon  as  the  postanesthetic  vomiting  has  ceased, 
followed  by  salines  and  high  enemas.  If  the  medicines  are  rejected 
by  the  stomach,  it  should  be  washed  out  and  salts  introduced  through 
the  stomach-tube.  Enemas  of  turpentine,  glycerin,  and  a  saturated 
solution  of  epsom  salt  should  be  given  every  hour,  followed  by  rectal 
irrigation  with  hot  salt  solution.  Intravenous  infusions  are  of  the 
greatest  value  in  stimulating  the  secretion  of  urine  and  inducing  active 
diaphoresis.  Cardiac  stimulants,  as  strychnin,  digitalis,  caffein,  and 
alcohol,  should  be  freely  given.  Sponge-baths  and  hot  packs  will 
often  relieve  the  intense  restlessness  and  high  temperature.  The  prac- 
tice of  abandoning  to  their  fate  patients  who  develop  generalized  peri- 
tonitis cannot  be  too  strongly  condemned.  While  the  great  majority 
of  such  patients  eventually  succumb  in  spite  of  all  treatment,  desperate 
cases  are  saved  occasionally  by  energetic  and  persistent  treatment. 


LAPAROTOMY   AND   OPERATIONS   UPON  THE   ABDOMEN.  23 1 

The  author  has  recently  seen  such  a  patient  recover  after  days  of  con- 
tinuous vomiting  of  intestinal  matter,  enormous  distention  of  the  ab- 
domen, a  temperature  of  108.5°  F.,  and  a  pulse  that  could  not  he  counted. 
In  this  case  every  available  cutaneous  vein  in  the  body  had  been  used 
for  saline  infusion.  Localized  abscesses  in  various  parts  of  the  abdom- 
inal cavity  are  not  infrequent  during  convalescence  from  a  diffuse  peri- 
tonitis. Their  presence  is  indicated  by  an  acute  rise  in  temperature 
and  pulse,  a  high  leukocytosis,  prostration,  and  the  occurrence  of 
sweats.  The  tenderness  may  be  slight  even  in  large  collections  of  pus, 
and  should  be  sought  for  carefully  by  abdominal  palpation  and  vaginal 
or  rectal  examination.  The  symptoms  will  promptly  subside  as  soon 
as  the  focus  is  located  and  adequately  drained. 

Fecal  fistula  not  infrequently  follows  appendicitis,  especially  if. 
the  appendix  and  cecum  are  greatly  infiltrated  and  surrounded  by  an 
abscess.  In  these  cases  removal  of  the  appendix  may  result  in  injury 
to  the  wall  of  the  gut,  and  a  ligature  placed  around  the  stump  may 
cut  through  before  it  is  tightened  sufficiently  to  occlude  the  lumen  of 
the  tube.  Under  these  conditions  a  fistula  may  often  be  prevented  by 
drawing  a  piece  of  omentum  over  the  stump  and  suturing  it  to  the  cecal 
wall.  The  treatment  of  fecal  fistula  consists  in  cleanliness  and  fre- 
quent dressings.  Drainage  should  be  removed  as  soon  as  the  sinus  is 
sufficiently  organized  to  remain  patent,  and  the  opening  allowed  to 
heal  by  granulation.  The  great  majority  of  these  cases  heal  sponta- 
neously. 

Ventral  hernia  frequently  follows  operations  for  acute  appendi- 
citis, especially  if  the  wound  is  allowed  to  remain  open  for  drainage. 
The  treatment  is  the  same  as  for  other  varieties  of  postoperative  ven- 
tral hernia. 

THE    AFTER-TREATMENT     OF     OVARIOTOMY    ACCORDING 
TO  HOWARD  A.  KELLY. 

Comparatively  full  details  of  treatment  following  most  abdominal 
operations  have  already  been  described  under  the  head  of  laparot- 
omy, but  certain  minor  details,  so  necessary  to  the  comfort  and  welfare 
of  the  patient,  have  been  so  clearly  and  forcibly  described  by 
Howard  A.  Kelly  that  I  feel  warranted  in  placing  his  ideas  in  full  before 
the  reader. 

"Before  leaving  the  operating  table  the  patient  is  given  a  high  rec- 
tal injection  of  one  pint  of  normal  salt  solution  at  a  temperature  of  ioS° 
F.     She  is  then  carried  to  her  room  and  placed  in  a  warm,  comfortable 


232  POSTOPERATIVE    TREATMENT. 

bed.  The  room  should  be  darkened  and  the  patient  left  in  exclusive 
charge  of  the  nurse,  who  should  under  no  circumstances  leave  her  alone 
for  a  minute  until  the  effects  of  the  anesthetic  have  worn  off.  Restraint 
must  be  exercised  while  under  the  effects  of  the  anesthesia  and  pass- 
ing off  only  to  the  extent  of  preventing  the  patient  from  falling  out  of 
bed  or  tossing  to  and  fro. 

"Position  in  Bed. — It  is  not  necessary  for  the  patient  to  remain 
persistently  upon  the  back;  on  the  contrary,  she  may  be  carefully 
turned  from  one  side  to  the  other  if  the  change  makes  her  more  com- 
fortable. 

"Use  of  Morphin. — If  after  the  effects  of  the  anesthetic  have  passed 
away  the  patient  is  very  restless,  or  if  she  has  severe  pain,  which  fre- 
quently follows  oophorectomy,  morphin,  |^  to  ^  grain,  may  be  given 
hypodermatically,  and  the  dose  repeated  if  sleep  during  the  first  night 
cannot  be  secured  without  it.  Milder  sedatives  are  useless,  but  mor- 
phin should  not  be  continued  longer  than  twenty-four  to  thirty-six 
hours.  If  the  patient  is  hysterical,  codein  may  act  better  than  mor- 
phin. Violent  movements  should  be  controlled  as  far  as  possible  by 
moral  suasion,  with  efforts  at  gentle  restraint.  Under  no  circum- 
stances should  a  woman  semiconscious  and  writhing  in  pain  be  placed 
in  a  canvas  strait- jacket  and  pinned  down  to  the  bed  by  force.  They 
are  far  more  liable  to  injury  in  this  way  than  if  left  uncontrolled. 

"Nausea. — The  nausea  from  the  anesthetic  is  variable,  being  most 
pronounced  after  long  operations;  it  usually  ceases  in  from  twenty- 
four  to  forty-eight  hours,  although  it  may  last  three  or  four  days,  or 
even  a  week.  Little  or  no  nourishment  should  be  given  at  first  while 
the  vomiting  is  active.  If  the  patient  is  weak  and  the  nausea  persists, 
nutrient  rectal  enemas  of  a  small  cupful  of  peptonized  milk  and  the 
yolks  of  two  eggs,  with  salt,  may  be  given  every  six  or  eight  hours 
Nausea  will  often  be  relieved  by  teaspoonfuls  of  very  hot  water,  or  a 
drop  or  two  of  tincture  of  capsicum  in  water,  or  a  quarter  of  a  drop 
of  creasote  in  a  teaspoonful  of  lime-water.  A  mustard  plaster  over  the 
pit  of  the  stomach  often  helps.  (For  treatment  of  severe  forms  of  vomit- 
ing by  washing  out  of  the  stomach  see  page  78.) 

"Toilet. — The  personal  care  of  the  patient  devolving  upon  the  nurse 
is  so  important  that  I  add  a  few  directions  about  cleanliness  and  toilet. 
As  soon  as  consciousness  returns  the  hands  and  face  are  bathed  in  cool 
water  and  the  mouth  cleansed  with  a  gauze  sponge  dipped  in  ice- water. 
If  there  is  a  tendency  to  choke  up  with  mucus,  the  fauces  must  be  wiped 


LAPAROTOMY   AND   OPERATIONS   UPON   THE   ABDOMEN.  233 

out  with  a  clean  napkin  used  far  back  in  the  throat.  When  the  patient 
is  strong  enough,  a  gargle  of  warm  water  relieves  the  thirst  and  the 
unpleasant  taste  of  ether  in  the  mouth.  The  head  must  be  kept  low, 
without  a  pillow  at  first,  to  assist  breathing  and  to  lessen  the  nausea. 
A  hair  pillow  under  the  flexed  knees  gives  a  more  comfortable  posi- 
tion. 

"Bathing. — The  morning  after  the  operation  the  patient  may  be 
given  an  alcohol  bath — one  part  alcohol  and  three  parts  water — at  a 
temperature  of  120°  F.  Beginning  with  face  and  arms,  carefully  plac- 
ing towels  under  the  parts  so  as  not  to  wet  the  bed,  and  exposing  small 
portions  at  a  time,  the  whole  body  may  be  washed  with  a  soft  gauze 
cloth.  The  alcohol  bath  should  be  given  during  the  first  forty-eight 
hours,  after  which  the  regular  daily  bath  of  warm  water  and  soap  may 
be  resumed. 

"Food.— The  first  food  given  should  be  a  teaspoonful  of  milk  or 
hot  weak  tea  at  half-hour  intervals,  increasing  the  quantity  as  the  stom- 
ach becomes  tolerant;  lime-water  may  be  added  to  the  milk.  Strong 
coffee  is  also  occasionally  valuable  as  a  stimulant.  Egg-albumen  is  a 
tasteless  and  most  nutritious  food.  It  is  prepared  by  beating  up  the 
whites  of  four  eggs  into  a  liquid  froth,  and  allowing  it  to  stand  in  a 
cool  place  for  an  hour  or  more,  when  50  c.c.  (about  2  ounces)  of 
liquid  albumen  may  be  drained  off,  leaving  the  frothy  part  behind. 
Another  way  of  preparing  albumen  is  to  pour  the  white  of  one  egg  over 
half  a  glass  of  finely  crushed  ice,  stirring  gently  and  adding  a  little 
sugar  and  lemon.  Egg-albumen  should  be  made  fresh  every  six  to 
twelve  hours,  according  to  the  time  of  year.  It  is  best  given  a  teaspoon- 
ful or  two  at  a  time,  mixed  in  two  or  three  tablespoonfuls  of  cold  water, 
with  a  little  sugar,  and  flavored  with  five  or  ten  drops  of  lemon-juice; 
if  preferred,  a  teaspoonful  of  sherry  wine  may  be  added. 

"Additional  articles  of  liquid  diet  are  chicken  broth,  beef -tea,  and 
the  various  gruels.  Hot  oyster-soup,  with  the  oysters  taken  out,  is  a 
valuable  and  appetizing  addition  to  the  diet-list  when  other  hquids 
have  become  tiresome.  Wine  whey  and  clam-juice  are  occasionally 
useful.  From  120  to  250  c.c.  (4  to  8  ounces)  of  nourishment 
will  be  taken  in  this  way  in  the  second  twenty-four  hours,  in- 
creased to  300  to  400  c.c.  (10  to  13  ounces)  in  the  third.  From 
the  third  or  fourth  to  the  seventh  day,  if  all  is  going  well,  soft 
diet  may  be  given.     This  consists  of  soft-boiled  eggs,  milk-toast,  bread, 


234  POSTOPERATIVE    TREATMENT. 

soups,  custards,  and  jellies,  with  milk-punch  or  egg-nog.     After  the 
first  week  stronger  diet  may  be  gradually  resumed. 

"As  the  widest  divergence  of  opinion  may  and  does  exist  as  to  what 
a  liquid  or  a  soft  diet  is,  I  add  hereto  a  diet-list  prepared  by  an  ex- 
perienced nurse. 

"DIET-LISTS. 
^^ Liquid  Food: 

"Milk. — Plain,  peptonized,  sterilized,  malted;  with  albumen,  milk- 
punch,  egg-nog,  koumiss. 

"Wines. — Grape-juice  (unfermented),  cocoa  cordial,  wine  whey, 
mulled  wine,  sherry  whip. 

"Broths. — Beef-tea,  beef  broth,  broiled  beef  essence,  chicken  broth, 
oyster  broth,  clam  broth,  somatose. 

"Soups. — Mock  bisque,  -tomato,  cream  of  rice,  cream  of  asparagus, 
cream  of  pea,  consomme,  bouillon. 
''Sojt  Foods: 

"Eggs. — Poached,  shirred,  soft-boiled. 

"Jellies. — Wine,  orange,  or  coffee  jelly. 

"Creams. — Apple  float;  whipped,  orange,  or  Spanish  cream;  cream 
of  tapioca,  cream  of  rice;  baked  custard  in  cups,  boiled  custard  with 
float,  tapioca  with  baked  apples,  arrow-root  blanc-mange,  orange  sher- 
bet, lemon  sherbet,  junket  (plain  or  made  with  wine),  panada. 

"SPECIAL   DIETS. 

'^Oysters  and  Sueethreads. — Creamed  oysters,  broiled  oysters,  oysters 
on  the  half-shell;    creamed  sweetbreads,  broiled  sweetbreads. 

"Eggs. — Poached,  shirred,  soft-boiled. 

"Beef. — Scraped  beef  sandwiches. 

"Birds. — Partridges  (broiled  or  roasted),  broiled  squab,  chicken 
stewed  with  rice. 

"Porridge. — Wheat  flakes,  oatmeal  (strained). 

"Thirst. — The  thirst  for  the  first  twelve  hours  after  abdominal 
section  is  sometimes  overpowering,  and  the  patient  in  her  desire  to  allay 
it  scarcely  knows  what  she  is  doing.  One  of  my  patients,  a  desperate 
ovariotomy  case,  reached  down  to  her  feet  and  pulled  up  the  hot-water 
bag,  from  which  she  drank  at  least  a  quart  of  warm  water.  Another, 
a  colored  girl,  with  general  suppurative  peritonitis,  and  with  a  drain- 
age-tube in  the  abdomen,  got  out  of  bed,  walked  into  the  hall,  and 
drank  a  large  quantity  of  water  from  the  spigot  of  the  water-cooler; 


LAPAROTOMY    AND    OPERATIONS    UI'ON    TUK    ABDOMEN.  235 

neither  of  Ihcm  was  apparently  hurt  by  her  experience.  (For  the 
treatment  of  this  impf)rlant  symptom  see  page  78.) 

"Irritability  of  the  Bladder  and  Decrease  in  Urinary  Excretion. 

— The  temporary  partial  suppression  of  urine  for  the  first  four  or 
live  days  after  an  abdominal  section  is  frequently  so  marked  as  to  give 
rise  to  a  fear  of  the  possibility  of  some  grave  renal  disturbance. 

"In  a  paper  by  W.  W.  Russel  ('Johns  Hopkins  Hospital  Reports,' 
1894),  after  a  careful  review  of  the  urinary  charts  of  many  cases,  the 
conclusion  was  reached  that  the  frequency  of  vesical  irritability  in  post- 
operative cases  was  due  to  the  retention  of  small  quantities  of  highly 
concentrated  urine  in  the  bladder.  This  theory  is  unquestionably 
correct,  for  a  noteworthy  increase  in  the  amount  of  urine  excreted  after 
saline  enemas  has  been  followed  by  a  marked  decrease  in  the  frequency 
of  catheterization,  and  in  vesical  irritability,  and  consequently  post- 
operative cystitis  or  vesical  irritability  now  rarely  occurs. 

"A  comparison  by  Clark  of  a  series  of  loo  cases  in  which 
saline  enemas  were  used,  with  a  series  of  loo  cases  without  them, 
shows  these  interesting  points :  '  The  natural  result  of  almost 
doubling  the  watery  constituent  of  the  urine  is  to  decrease  the  specific 
gravity.  The  specific  gravity  of  cases  in  which  the  enemas  are  not 
given  ranges  between  1025  and  1030,  while  those  with  it  show  a  reduc- 
tion to  an  average  of  1021.' 

"There  appears  to  be  a  further  explanation  for  the  greater  excre- 
tion of  urine  in  the  cases  which  have  the  saline  enemas  than  that  it  is 
merely  due  to  an  increase  in  the  amount  of  water  taken  into  the  system. 
The  nausea  and  vomiting  following  anesthesia  usually  disappear  by  the 
end  of  the  first  twenty-four  hours,  after  which  the  imbibition  of  water 
has  not  been  restricted  in  either  series. 

"Notwithstanding  the  fact  that  in  both  series  of  cases  about  the 
same  quantity  of  w^ater  is  taken  by  the  mouth,  the  excretion  in  one 
remains  very  low  for  three  days,  at  no  time  being  above  505  c.c. 
while  the  other  shows  not  less  than  600  c.c,  or  over  100  cubic  cen- 
timeters more  urine  passed  daily  by  the  patients  who  have  had  the 
enemas.  From  this  observation  it  would  appear  thatthe  persistent 
renal  torpidity  is  due  to  the  irritant  or  toxic  effects  of  the  greatl}-con- 
centrated  urine,  and  by  supplying  the  body  with  a  Hter  of  salt  solu- 
tion this  partial  suppression  is  to  a  great  extent  prevented,  and  the 
kidney  at  once  resumes  its  normal  function  as  soon  as  the  patient 
begins  to  take  water. 


236  POSTOPERATIVE    TREATMENT. 

"Catheter. — The  catheter  should  only  be  used  to  draw  the  urine, 
if  the  patient  is  unable  to  pass  it  naturally  after  six  or  eight  hours,  and 
then  the  utmost  care  must  be  taken  to  pass  a  clean  catheter,  through  a 
clean  urethral  orifice,  under  inspection.  If  the  catheter  has  to  be  used 
at  all,  its  use  must  be  discontinued  as  soon  as  possible.  If  vesical  ir- 
ritability is  persistent,  it  will  improve  upon  taking  spirits  of  nitrous 
ether,  20  to.  30  drops,  every  two  hours,  or  5  drops  of  copaiba  in  cap- 
sules three  times  a  day.  Balsch  ('Miinchener  medicinische  Wochen- 
schrift')  states  that  repeated  catheterization  may  be  avoided  and  the 
bladder  made  to  assume  its  normal  contractility  by  injecting  into  the 
distended  bladder  20  cubic  centimeters  of  a  sterilized  2  percent 
solution  of  boric  acid  in  glycerin.  In  the  majority  of  cases  this  pro- 
cedure is  followed  by  an  evacuation  of  the  bladder  without  tenesmus 
in  from  five  to  ten  minutes,  and  the  patient  usually  is  thereafter  able 
to  urinate  spontaneously. 

"Bowels. — I  have  often  noticed  that  surgeons  grow  too  anxious 
and  work  too  hard  to  get  the  bowels  moved  for  the  first  time.  If  the 
patient  is  doing  well  in  other  ways,  it  need  cause  no  worry  should  the 
bowels  be  sluggish  and  not  respond  until  as  late  as  the  fifth  or  sixth 
day.  Often  after  two  or  three  days  of  active  efforts  if  the  patient 
is  left  quite  alone  they  move  spontaneously  in  six  or  eight  hours. 

"As  a  routine  line  of  treatment  I  give  on  the  evening  of  the  second 
day  something  which  will  move  the  bowels  on  the  following  morning. 
Calomel  will  be  found  to  be  the  most  efficacious,  and  is,  as  a  rule,  best 
borne  by  the  patient.  It  can  be  given  in  one  dose  of  2  or  3  grains, 
or  |-  to  ^  of  a  grain  may  be  given  every  hour  until  the  same  amount  is 
reached,  followed  in  the  morning  by  6  to  8  ounces  of  a  solution  of  mag- 
nesium citrate.  About  two  hours  later  an  enema  of  100  c.c.  of  olive 
oil  with  30  c.c.  of  glycerin  should  be  injected  as  high  as  possible  into 
the  rectum.  If  this  is  not  effective,  four  to  six  hours  may  be  allowed 
to  elapse  before  another  attempt  is  made  with  an  injection,  consisting 
of  a  pint  of  water  at  a  temperature  of  110°  F.  and  soapsuds. 

"A  satisfactory  saline  enema  much  used  by  C.  P.  Noble  is  the  fol- 
lowing concentrated  solution  of  the  sulfate  of  magnesia: 

Magnesium  sulfate, §  ij 

Oil  of  turpentine, O  ss 

Glycerin, §  j 

Water  enough  to  make §  iv 

Mix  and  inject  in  bowel. 


LAPAROTOMY   AND   OPERATIONS   UPON   THE   ABDOMEN.  237 

"It  is  not  advisable  to  use  more  than  three  enemas  during  the  third 
day;  it  is  better  to  assist  the  calomel  by  castor  oil  or  magnesium  sulfate 
in  half-ounce  doses,  or  by  a  pill  of  aloin,  strychnin,  and  belladonna. 
When  the  bowels  are  once  opened,  they  should  be  kept  open  by  a  move- 
ment at  least  every  other  day. 

"Tympanites,  v^^hich  often  occasions  much  distress,  is  usually 
speedily  relieved  by  the  free  evacuation  of  the  bowels.  Drop  doses  of 
tincture  of  capsicum,  or  a  few  drops  of  tincture  of  nux  vomica  in  a  tea- 
spoonful  of  hot  pepper  tea,  are  valuable  adjuvants.  A  rectal  enema 
of  three  ounces  of  milk  of  asafetida  will  also  often  relieve  it. 

"Temperature. — The  temperature  must  always  be  carefully 
watched.  On  the  second  or  third  day  it  is  commonly  elevated  to  100° 
F.,  or  even  ioi°  F.,  but  it  usually  drops  with  the  first  free  movement 
of  the  bowels.  This  slight  rise  in  temperature  appears  to  be  due  to 
the  absorption  of  a  fibrin  ferment,  and  it  may  in  exceptional  cases  be 
prolonged  for  several  days  beyond  the  usual  period.  A  persistent  tem- 
perature, however,  above  100°  is  in  most  cases  due  to  infection  either 
of  the  wound  or  in  the  peritoneum.  A  sudden  rise  in  temperature, 
sometimes  attended  with  a  chill,  toward  the  end  of  the  first  week,  is 
often  the  first  indication  of  suppuration  in  the  abdominal  wall.  The 
wound  should  be  inspected  immediately  for  any  hard,  red,  tender  areas 
on  one  side  or  the  other,  the  stitch  or  stitches  at  that  point  removed, 
and  the  lips  of  the  incision  slightly  separated,  to  favor  the  discharge  of 
pus.     When  the  pus  has  escaped,  the  temperature  falls  at  once. 

"Pulse. — The  pulse  is  likely  to  remain  quickened  20  or  30  beats 
or  more  for  three  or  four  days  after  any  severe  operation.  If  the  gen- 
eral condition  is  good,  and  the  pulse  full  and  compressible,  this  need 
cause  no  anxiety.  The  normal  course  is  a  steadily  falling  pulse  after 
operation,  falling  less  rapidly  if  there  is  much  pain.  A  falHng  pulse 
is  a  good  sign ;  a  rising  pulse  always  calls  for  investigation.  In  general, 
a  pulse  of  from  120  to  130  beats  needs  watching;  a  pulse  of  140  beats 
needs  closer  watching;  a  pulse  of  150  beats  needs  anxious  watching; 
a  patient  with  a  pulse  of  i6o  beats  does  not,  as  a  rule,  -recover  unless 
it  begins  to  fall  within  six  to  twelve  hours  after  the  operation.  Neither 
the  temperature  nor  the  pulse,  however,  should  be  studied  alone,  but 
always  in  association.  If  the  pulse  is  high — from  120  to  140  beats — 
combined  with  a  high  temperature  after  the  lirst  day,  when  the  bowels 
have  been  freely  moved,  infection  has  probably  taken  place.  The 
most  satisfactory  sign  of  progress  is  a  free  evacuation  of  the  bowels, 
with  a  pulse  and  temperature  dropping  together. 


238  POSTOPERATIVE    TREATMENT. 

"Facial  Expression. — Facial  expression  is  a  sign  scarcely  less 
significant  than  the  temperature  and  pulse,  and,  taken  together  with 
these  forms,  is  a  good  index  of  the  general  condition.  A  bright  natural 
expression  is  to  be  looked  for  during  the  normal  convalescence;  a 
flushed,  dusky,  anxious,  haggard,  or  a  lack-luster  expression  is  indica- 
tive of  complications. 

"Dressing  of  the  Wound. — Unless  some  special  cause  arises,  the 
wound  need  not  be  dressed  until  the  tenth  day,  when  fresh  gauze  and 
cotton  dressings  should  be  put  on  with  the  dressing  forceps.  The 
bandage  may  be  changed  daily,  and  the  back  well  rubbed  with  a  solu- 
tion of  alcohol  and  water,  half  and  half.  Boric  acid  and  bismuth  pow- 
der are  also  good  to  rub  into  the  back.  This  rubbing  is  the  best  treat- 
ment for  the  severe  pain  so  constantly  felt  in  the  back. 

"Sutures. — The  use  of  buried  catgut  suture  may  relieve  the  pa- 
tient, if  explained,  of  considerable  anxiety,  for  often  the  removal  of 
sutures  is  looked  forward  to  with  great  dread.  The  abdominal  dress- 
ings need  not  be  disturbed  until  the  tenth  day  except  in  case  of  wound 
infection.  They  should  be  carefully  lifted  off  and  replaced  by  several 
layers  of  fresh  sterilized  gauze.  If  they  have  become  adherent  to  the 
incision,  a  little  sterilized  water  poured  on  will  rapidly  loosen  them. 
The  skin  about  the  incision  should  not  be  cleansed  until  about  the 
fourteenth  day.  Pledgets  of  cotton  wet  with  dilute  alcohol  are  best 
for  this  purpose.  The  catgut  sterilized  by  the  cumol  method  is  usually 
absorbed  by  the  eighth  to  the  tenth  day.  Silkworm-gut  sutures  are 
removed  on  the  tenth  to  the  fourteenth  day.  First  expose  the  loop  by 
pulling  up  the  suture  a  little  with  forceps,  then  cut  it  close  to  the  skin 
and  draw  it  out  toward  the  side  on  which  it  is  cut,  to  avoid  pulling  the 
edges  of  the  wound  apart.  Adhesive  straps  across  the  wound  after 
removing  the  sutures  are  sometimes  necessary.  If  the  bandage  is  kept 
well  in  place,  and  put  on  snugly  every  time  the  wound- surfaces  will 
naturally  remain  in  close  approximation. 

"Convalescence. — After  ten  or  twelve  days  usually  the  patient 
may  be  propped  up  with  pillows  or  on  a  bed-rest;  and  in  from  seven- 
teen to  twenty-one  days,  according  to  the  rapidity  with  which  strength 
is  regained,  she  may  spend  part  of  the  time  in  a  recUning  chair  or  on 
a  sofa.  Throughout  the  convalescence  she  must  avoid  straining  the 
abdominal  muscles.  While  still  abed  she  must  not  raise  herself  to  a 
sitting  posture  or  change  her  position  without  aid.  Later  she  must 
not  stoop  or  lift  heavy  weights.     During  active  vomiting  the  least 


LAPAROTOMY   AND   OPERATIONS   UPON   THE   ABDOMEN.  239 

strained  position  is  lying  on  the  side  with  the  Ijody  slightly  flexed,  or  on 
the  back  with  the  knees  drawn  up  resting  on  a  pillow.  At  the  end  of 
the  fourth  or  fifth  week  she  should  be  able  to  walk  around  and  perhaps 
go  downstairs.  All  bodily  movements  should  be  gentle  at  first.  The 
patient  should  not  sit  up  long  enough  at  first  to  grow  tired  of  the  new- 
ness of  it,  and  later  on  she  should  avoid  tiring  herself  on  her  feet.  It 
is  best  not  to  hasten  the  getting  out  of  bed,  as  a  prolonged  absolute 
rest  is  an  important  element  in  securing  complete  restoration  to  health. 
Heavy  work  and  exhausting  exercise  of  all  kinds  must  be  avoided. 

"The  convalescence  is  by  no  means  at  an  end  when  the  patient  is 
able  to  return  to  her  home.  Disappointment  will  frequently  be  avoided 
if  she  is  warned  of  this  beforehand,  and  kept  under  observation  for  a 
year  or  more  while  regaining  her  physical  and  nervous  balance  and 
passing  the  period  of  any  unpleasant  sequels,  such  as  flushes,  sweatings, 
giddiness,  and  various  other  nervous  manifestations.  Sometimes  some 
of  the  original  discomforts  persist  for  months,  only  disappearing  grad- 
ually, so  that  complete  recovery  to  health  does  not  take  place  until 
after  a  year  or  a  year  and  a  half. 

"Fresh  air,  rest,  diet,  and  tonic  treatment,  with  encouragement, 
are  the  most  important  aids  in  convalescence.  Change  of  air  and 
scenes  are  of  the  greatest  value  in  bringing  about  complete  restoration 
to  health.  The  golf  field  is  the  best  form  of  moderate  exercise  I  know 
of,  and  will  prove  an  invaluable  adjuvant  as  soon  as  the  patient  is  able 
to  take  a  little  active  out-of-door  exercise." 

PYOSALPINX,  ABSCESS  OF  OVARY,  ETC. 
The  after-treatment  depends  largely  upon  the  extent  of  the  oper- 
ation, adhesions  of  the  intestines,  etc.  When  it  is  possible  to  remove 
the  pus-tubes  without  rupture,  causing  the  escape  of  pus  into  the  pel- 
vis or  abdominal  cavity,  careful  toilet  of  the  peritoneal  cavity  is  usually 
all  that  is  required,  after  which  the  abdominal  wound  may  be  closed 
and  the  after-treatment  will  be  the  same  as  after  any  septic  operation; 
but  should  an  abscess  rupture  during  an  operation  or  should  pus  escape 
accidentally,  the  pelvis  should  be  thoroughly  cleansed  with  sponges, 
and  then  the  sides  of  the  incision  may  be  pulled  up  and  as  much  hot 
salt  solution  poured  in  as  the  pelvis  will  hold.  Kelly  recommends  that 
the  hot  salt  solution  should  be  stirred  about  in  the  pelvis  with  the  hand 
or  with  a  sponge  on  a  holder,  and  the  water  then  sponged  out  and  more 
poured  in.     This  may  be  repeated  several  times  until  the  surgeon  is 


240  POSTOPEEATIVE   TREATMENT. 

satisfied  that  the  pus  has  been  well  diluted  and  removed.  No  drain- 
age will  then  be  necessary.  If,  however,  there  is  a  distinct  focus,  of 
infection  or  an  injured  bowel  left  behind,  a  vaginal  gauze  drainage 
should  be  inserted  behind  the  cervix. 

Pelvic  Abscess. — If  the  operation  discloses  a  large  pelvic  abscess 
with  a  widespread  or  a  general  purulent  peritonitis,  the  course  pursued 
by  the  operator  must  depend  upon  the  condition  of  the  patient.  The 
best  plan  is  to  make  a  posterior  vaginal  counteropening,  to  irrigate 
rapidly,  clearing  out  all  accessible  pus  with  a  sponge,  paying  special 
attention  to  the  pelvic  and  renal  fossas.  The  abscess  walls  with  the 
ovary  or  pus-tube  should  be  carefully  enucleated.  When  the  patient's 
condition  will  permit,  the  entire  abdominal  cavity  should  be  washed 
out,  and  the  separate  coils  of  intestines  drawn  up  and  carefully  wiped, 
so  that  as  far  as  possible  every  trace  of  pus  is  removed.  Careful  but 
thorough  flushing  with  normal  salt  solution,  repeated  several  times, 
should  be  done  as  rapidly  as  possible.  A  Kberal  gauze  drainage  should 
then  be  inserted  through  the  abdominal  incision,  pushed  down  into  the 
pelvis,  and  drawn  out  through  the  vaginal  incision.  In  this  way  sev- 
eral yards  of  gauze  may  be  employed  and  gradually  removed  by  the 
third  or  fourth  day.  Some  surgeons  prefer  the  insertion  of  a  large  glass 
drainage-tube  through  the  lower  portion  of  the  abdominal  incision, 
which,  together  with  a  small  gauze  drainage  via  the  vagina,  is  ordi- 
narily sufficient,  but,  in  our  experience,  the  more  thorough  the  drain- 
age, the  better  the  prospects  of  recovery. 

The  following  case,  reported  by  R.  C.  Turck,  of  Chicago  ("Medi- 
cal Standard,"  May,  1903),  is  typical  of  many  of  the  severe  cases  of  this 
character  and  contains  an  abundance  of  interesting  and  instructive 
features : 

"Miss  E.,  age  twenty-eight.  Double  pyosalpinx,  appendicitis,  general  peritonitis.  En- 
tered hospital  with  symptoms  of  a  general  peritonitis.  Had  had  abortion  with  subsequent 
septic  infection  five  weeks  previously;  condition  desperate;  had  been  transfused  intra- 
venously before  taken  to  the  hospital  in  ambulance.  Examination  showed  intense, 
diffuse  abdominal  pain,  distention,  tympanites,  pulse  weak  and  rapid,  temperature 
101°  F.,  respiration  28;  pelvic  region  extremely  tender,  apparently  a  mass  of  inflamed 
and  adherent  viscera.  Treated  for  eight  days  by  constant  hot  fomentations,  liquid 
diet,  morphin,  nutrient  enemas,  lysol  douches,  etc.,  reducing  pain,  temperature,  disten- 
tion, and  inflammation. 

"Operation. — Median  abdominal  incision.  Pelvis  and  abdomen  filled  with  floccu- 
lent,  serosanguineous  fluid;  pelvic  viscera,  bowel,  and  omentum  formed  an  agglu- 
tinated mass.  Broke  up  adhesions  between  uterus,  ovaries,  both  enlarged  tubes  and 
pelvic  wall,  bladder,  rectum,  bowel,  and  omentum.  Left  ovary  and  tube  lying  in 
bottom  of  pelvis.     Amputated  together  with  uterine  horn.     Obliged  to  cut  away  large 


LAPAROTOMY   AND   OPERATIONS   UPON   THE   ABDOMEN.  241 

amount  of  adherent  omentum.  Right  tube  also  directed  downward  with  vermiform 
appendix,  highly  inflamed,  closely  adherent  to  it.  Removed  appendix  and  tube  and 
part  of  ovary.  Great  amount  of  raw  surface,  with  much  oozing.  Toilet  with  dry  sponges. 
Cut  through  posterior  vaginal  wall  (Douglas's  pouch),  and  packed  deep  pelvis  with 
iodoform  gauze,  carrying  end  out  through  the  vagina.  Inserted  large  Mikulicz  drain 
deeply  through  abdominal  wound,  with  glass  tube  in  center  of  drain.  Gave  1000  c.c. 
normal  salt  under  breasts  on  operating  table.  Strychnin  hypodermatically.  Patient  left 
table  in  practical  collapse. 

"After-treatment. — Strychnin,  .}(j  grain  hypodermatically  every  two  hours;  normal 
salt  solution,  temperature  108°  F.  One  pint  by  the  rectum  every  three  hours.  Drainage 
during  the  first  twenty-four  hours  twelve  ounces  from  tube;  second  day,  seven  ounces; 
then  an  average  of  three  ounces  for  six  days.  Normal  salt  per  rectum  not  retained  after 
fourth  day.  Temperature  never  above  100°  F.  after  forty-eight  hours.  Removed  tube 
on  eighth  day;  also  part  of  gauze  below  and  all  of  the  Mikulicz  drain;  irrigated  and 
repacked;  established  through-and-through  drainage  and  irrigation  {i.  e.,  in  abdominal 
wound  and  out  vagina).  Temperature  normal  after  seventeenth  day.  Wound  gradu- 
ally healed.  Left  hospital,  walking,  on  the  thirty-fifth  day.  Wounds  completely  healed, 
with  patient  in  excellent  condition,  gaining  weight  and  strength,  no  pain,  at  end  of  seventh 
week." 

Pelvic  abscesses  after  thorough  evacuation  should  be  carefully 
packed  with  iodoform  gauze  or  iodoform  gauze  dipped  in  balsam  of 
Peru.  The  patient  must  be  kept  absolutely  at  rest,  bowels  freely  open. 
Antiseptic  hot  vaginal  douches  frequently  afford  relief.  If  the  condition 
of  the  patient  remains  good,  the  gauze  packing  should  not  be  disturbed 
for  three  or  four  days  or  longer,  or  until  the  packing  becomes  loosened, 
when  all  the  gauze  may  be  removed  with  a  suitable  pair  of  forceps, 
and  the  cavity  cleansed  with  hydrogen  peroxid  or  boric-acid  solution, 
and  a  fresh  iodoform  packing  applied.  This  cleansing  or  dressing 
is  renewed  daily,  preferably  by  using  speculum  and  dressing  forceps ' 
instead  of  the  fingers.  Some  surgeons  prefer  to  withdraw  the  gauze 
drainage  slowly,  removing  three  or  four  inches  daily  and  not  washing 
out  the  sac  until  the  gauze  is  all  removed — by  about  the  tenth  day. 
If,  however,  the  pelvic  peritoneal  cavity  is  opened,  the  pus  must  be 
thoroughly  removed,  the  cavity  wiped  out  and  packed,  and  irrigation, 
if  used  at  all,  must  be  in  small  quantities  and  with  the  utmost  care. 
In  vaginal  drainage  great  care  is  necessary  to  avoid  a  fecal  fistula ;  not- 
withstanding the  greatest  precaution,  a  small  opening  into  the  bowel 
may  be  made,  but  will  usually  heal  quickly  if  the  cavity  is  well  packed 
with  gauze  so  as  to  prevent  fecal  matter  entering  the  abscess  sac.  WTien 
this  accident  happens,  the  gauze  must  be  removed  daily  and  the  pus 
cavity  well  irrigated,  followed  by  a  firm  application  of  fresh  gauze. 
When  the  cellular  tissue  is  more  or  less  honeycombed  with  multiple 
17 


242  POSTOPERATIVE    TREATMENT. 

abscesses,  the  progress  of  a  case  will  necessarily  be  slow  and  may  require 
repeated  puncture.  If  the  patient  does  not  improve,  or  if  the  pain, 
tenderness,  and  elevation  of  pulse  and  temperature  indicate  further 
extension  of  infection,  or  if  all  the  pus-cavities  have  not  been  evacuated, 
abdominal  incision  to  secure  perfect  drainage  may  become  necessary. 

APPENDICULAR  ABSCESS,  PYOSALPINX,  OR  SEPTIC 
PERITONITIS. 

Method  of  Drainage  after  Operation   (Nicholas  Senn). — "At 

present  there  are  three  methods  of  drainage  in  general  use:  (i)  tubu- 
lar drainage;  (2)  capillary  drainage;  (3)  a  combination  of  tubular  and 
capillary  drainage.  All  these  methods  have  their  advocates  and  are 
applicable  under  certain  circumstances.  No  one  method  of  drainage 
will  answer  in  all  cases. 

"Tubular  Drainage. — Tubular  drainage  is  specially  indicated  in 
cases  in  which  the  abdominal  cavity  contains  pus.  The  tubes  employed 
are  made  of  either  glass  or  soft  rubber.  Keith's  glass  drains  answer  an 
excellent  purpose  in  draining  the  lowest  portion  of  the  abdominal  cavity. 
They  should  be  slightly  curved  at  the  abdominal  end,  so  as  to  reach  the 
floor  of  the  pelvic  cavity  without  making  harmful  pressure  against  the 
bladder.  Frequent  aspiration  of  the  contents  of  the  drain  is  necessary 
for  the  purpose  of  removing  the  fluid  inflammatory  product  as  soon  as  it  is 
formed.  The  rubber  drain  answers  the  same  purpose,  but  it  is  properly 
accused  of  causing  more  mechanical  irritation  than  the  smooth  glass 
tube.  Prolonged  tubular  drainage  has  not  infrequently  caused  intes- 
tinal fistula  by  pressure.  It  is  for  this  reason  that  I  almost  invariably 
surround  the  rubber  or  glass  tube  with  a  few  layers  of  iodoform  gauze 
securely  fastened  to  the  tube.  In  draining  the  pelvic  portion  of  the 
abdominal  cavity  I  frequently  use  two  drains  the  size  of  the  little  finger, 
one  on  each  side,  brought  out  through  the  same  opening  in  the  lower 
angle  of  the  wound.  In  draining  the  lumbar  regions  and  through  the 
vagina  rubber,  drains  should  be  employed. 

"Capillary  Drainage. — Capillary  drains  are  frequently  employed 
as  substitutes  for  the  tubular  drains,  and,  in  addition,  must  often  be  re- 
lied upon  as  an  important  hemostatic  resource  in  arresting  parenchy- 
matous oozing.  Iodoform  or  steriHzed  gauze  is  usually  employed  as 
a  capillary  drain  in  draining  the  abdominal  cavity  for  peritonitis.  Bar- 
denheuer  first  resorted  to  strips  of  iodoform  gauze  in  draining  the  peri- 
toneal cavity.     The  greatest  objections  to  this  method  of  drainage  are 


>  LAF^AROTOMY    AND    OPERATIONS    UPON    THE    ABDOMEN.  243 

the  danger  from  iodoform  poisoning  if  a  considerable  ciuantity  of  gauze 
is  used,  the  difficulty  of  removing  the  gauze,  and  llic  likelihood  of  a  ven- 
tral hernia  as  a  legacy. 

"The  Mikulicz  Drain. — The  name  of  Mikulicz  is  connected 
with  a  special  method  of  gauze  drainage  of  his  own  device,  familiarly 
known  as  the  Mikulicz  iodoform  gauze  or  tampon  or  drain,  which  has 
proved  of  the  greatest  value  in  abdominal  operations  and  in  the  surgi- 
cal treatment  of  peritonitis.  The  typical  Mikulicz  tampon  is  made  by 
taking  a  piece  of  iodoform  gauze  the  size  of  a  large  handkerchief,  to 
the  center  of  which  a  strong  piece  of  aseptic  silk  thread  is  stitched. 
When  used,  it  is  arranged  as  a  pouch  and  is  carried  by  means  of  a  curved 
forceps  to  the  bottom  of  the  pelvis  and  filled  with  strips  of  iodoform 
gauze,  the  free  end  of  the  silk  thread  issuing  from  the  mouth  of  the 
pouch.  When  it  is  desired  to  remove  the  drain,  the  gauze  strips  are 
removed  and  the  pouch  removed  by  making  traction  upon  the  string. 
Mikulicz  speaks  of  an  iodoform  gauze  drain,  and  any  surgeon  who  has 
had  considerable  experience  in  abdominal  surgery  can  testify  to  the 
fact  that  when  the  Mikulicz  drain  is  called  for  we  are  frequently  dealing 
with  large  cavities  requiring  an  enormous  amount  of  gauze.  It  is  in 
such  cases  that  we  must  learn  to  fear  iodoform  gauze,  because  the 
cases  are  by  no  means  isolated  in  which  a  gauze  drain  composed  ex- 
clusively of  iodoform  gauze  has  been  the  immediate  cause  of  death  from 
iodoform  intoxication.  This  is  particularly  liable  to  occur  in  cases 
in  which  the  patient's  kidneys  are  not  functionating  properly  or  are 
diseased.  It  is  in  dealing  with  this  class  of  cases  that  the  elimina- 
tion of  iodoform  is  accomplished  with  great  difficulty,  and  hence 
when  accumulation  occurs,  death  is  liable  to  follow  from  intoxication. 
Again  there  are  persons  who  are  extremely  susceptible  to  the  local  and 
general  toxic  effects  of  iodoform.  A  very  small  quantity  of  this  sub- 
stance may  prove  fatal  from  intoxication.  It  is,  therefore,  advisable, 
in  using  the  Mikuhcz  drain,  to  limit  the  iodoform  gauze  to  an  outer  layer 
or  two  and  pack  the  pouch  with  ordinary  sterilized  gauze.  Drainage 
by  using  sterilized  wicking  has  been  popular  in  Germany  for  a  num- 
ber of  years,  and  in  many  cases  has  answered  an  excellent  purpose. 
It  has  never  found  its  way  to  any  extent  into  America,  where  gauze 
is  employed  in  preference." 

A  most  excellent  method  of  securing  capillary  drainage  has  been 
described  by  R.  T.  Morris.  To  avoid  the  danger  of  hard  and  soft 
tubes  and  of  unprotected  gauze,  he  recommends  wicks,  which  he  em- 


244  POSTOPERATIVE    TREATMENT. 

ploys  in  a  peculiar  way.  The  simplest  wick  consists  of  a  little  roll  of 
absorbent  bichlorid  gauze,  around  which  are  wrapped  a  couple  of  thick- 
nesses of  Lister's  protective  silk.  The  gauze  protrudes  a  little  from 
each  end  of  the  cylinder,  and  a  few  small  fenestra  in  the  protective 
silk  allow  the  serum  to  reach  the  gauze  elsewhere.  In  certain  cases 
in  which  injections  through  a  tube  are  desirable,  the  soft  tube  may  be 
surrounded  by  this  wick.  When  a  large  gauze  packing  for  the  pelvis 
or  abdomen  is  needed,  an  apron  of  the  silk  can  expand  over  the  gauze 
and  protect '  against  intestinal  adhesions.  This  method  of  drainage 
possesses  great  advantages  over  ordinary  tubular  and  capillary  drainage 
as  heretofore  described,  and  recommends  itself  more  especially  in  the 
surgical  treatment  of  diffuse  septic  peritonitis.  The  prolonged  contact 
of  gauze  with  a  serous  surface  is  very  prone  to  give  rise  to  permanent  ad- 
hesions, as  every  clinician  knows.  In  employing  gauze  in  draining 
the  peritoneal  cavity  it  is  necessary  to  use  long  strips,  which  should  be 
inserted  some  distance  in  different  directions  and  brought  out  at  the 
same  place  and  fastened  together  with  a  safety-pin.  Van  Hook  has 
shown  by  his  experiments  that  the  gauze  drains  more  freely  if  the  ex- 
ternal ends  of  the  strips  are  left  long  and  placed  on  the  side  of  the  pel- 
vis below  the  level  of  the  wound. 

Drainage  must  be  dispensed  with  as  soon  as  possible,  in  order  to  pre- 
vent adhesions  and  to  enable  the  surgeon  to  close  the  incision  by  secon- 
dary suturing,  an  important  precaution  against  the  formation  of  a  ven- 
tral hernia.  The  strips  should  be.  shortened,  and  one  after  the  other 
removed  as  the  indications  for  drainage  disappear. 

Combined  Tubular  and  Capillary  Drainage. — The  simultaneous 
use  of  a  "tubular  and  capillary  drain  is  an  excellent  method  of  securing 
drainage.  It  is  made  by  packing  loosely  a  glass  drain  of  proper  length 
and  size  with  strips  of  gauze  or  aseptic  wicking.  This  manner  of  drain- 
age is  especially  useful  when  the  inflammatory  product  is  serum  instead 
of  pus.  It  does  away  with  the  annoyance  and  risks  of  removing  the 
transudate  at  frequent  intervals,  as  is  necessary  in  the  employment  of 
simple  tubular  drainage.  If  it  is  the  design  of  the  surgeon  to  resort 
to  frequent  irrigation  after  the  operation,  tubular  drainage  is  necessary, 
but  to  this  can  be  added  capillary  drainage  by  inserting  strips  of  gauze 
into  localities  that  would  not  be  reached  by  the  irrigating  fluid. 


LAPAROTOMY   AND   OPERATIONS   UPON   THE   ABDOMEN.  245 

HERNIA. 

Operations  for  the  radical  cure  of  hernia  arc  usually  performed 
under  aseptic  precautions.  The  aflcr-drcssings  consist  of  iodoform 
gauze  or  a  pad  of  plain  gauze  or  lint,  or  the  wound  is  hermetically 
sealed  with  collodion.  In  very  fat  subjects  a  small  gauze  drain  at  the 
lower  angle  of  the  wound  should  be  introduced  and  allowed  to  remain 
for  two  days,  to  avoid  the  accumulation  of  serum.  In  the  great  ma- 
jority of  cases,  however,  no  drainage  is  necessary.  An  abundance  of 
gauze  dressings  are  applied,  over  which  a  bandage  is  carefully  placed, 
not  only  around  the  pelvis,  but  around  the  limbs.  Some  surgeons  also 
use  an  elastic  bandage  on  the  outside  of  the  dressings.  This  is  appHed 
in  the  form  of  a  figure  of  8  around  the  limbs  and  pelvis. 


Fig.  67. — Double  Spica  Bandage. — {After  Bassini.) 

If  the  dressings  become  soiled,  or  there  seems  to  be  excessive  ooz- 
ing, they  should  be  changed  promptly.  To  prevent  the  dressings  be- 
coming soiled,  guttapercha  tissue  or  a  piece  of  faconet  may  be  fastened 
over  the  dressing  in  such  a  manner  as  to  prevent  any  dribbling  of  urine. 
In  young  children  it  is  best  to  put  on  a  fixed  dressing  with  collodion. 

After-treatment. — The  patient  should  observe  the  recumbent 
position,  and  must  avoid  all  exertion  and  straining  during  the  period 
of  convalescence.  He  should  not  be  allowed  to  Hft  himself  in  bed. 
It  often  happens  that  the  comfort  of  tJie  patient  may  be  increased  by 


246 


POSTOPERATIVE    TREATMENT. 


allowing  the  thighs  to  be  kept  a  little  flexed,  by  introducing  a  pillow 
beneath  the  knees.  In  male  patienfs  retention  of  urine  is  occasionally 
complained  of. 

The  dieting  of  the  patient  sliould  be  upon  the  lines  observed  in  the 
after-treatment  of  cases  of  abdominal  section.  Opium  should  not  be 
administered  unless  distinctly  indicated.  The  bowels  should  be  opened 
on  the  fourth  day  by  an  enema,  unless  previously  relieved.  Flatulent 
distention  of  the  belly  may  be  relieved  by  the  use  of  the  rectal  tube, 
or,  if  severe  and  persistent,  by  means  of  a  saline  aperient.     In  some 


Fig. 


rare  cases  a  severe  diarrhea  sets  in  within  a  day  or  so  of  the  operation, 
and  is  not  only  very  difhcult  to  cope  with,  but  may  soon  lead  to  death 
from  exhaustion. 

The  drainage-tube,  if  employed,  should  be  removed  within  forty- 
eight  hours  in  ordinary  cases  that  are  doing  well.  The  sutures  may 
be  taken  out  on  the  eighth  day  or  later.  The  wound  should  be  dressed 
whenever  the  bandage  becomes  loose,  and  the  parts  around  must  be 
frequently  washed  with  hydrogen  dioxid  or  alcohol,  and  kept  scrupu- 
lously clean  and  dry  with  powdered  zinc  stearate. 


LAPAROTOMY    AND    OPERATIONS    UPON    TIIK    ABDOMEN.  247 

The  patient  should  not  Ijc  allowed  to  f^et  up  until  three  weeks  have 
elapsed  after  the  operation,  and  then  only  if  the  wound  is  sound.  The 
question  of  a  supporting  bandage  or  a  truss  will  then  have  to  be  con- 
sidered. If  the  surgeon  has  been  able  to  perform  a  radical  cure  at  the 
time  of  the  herniotomy,  no  truss  need  be  worn,  otherwise  a  light  truss 
will  be  required.  In  the  case  of  a  large  femoral  hernia  it  is  difficult  to 
prevent  recurrence,  and  hence  a  truss  is  usually  advisable. 

Complications. — The  most  important  complication  occurring  dur- 
ing convalescence  is  suppuration,  which  takes  place  occasionally,  and 
varies  in  extent  according  to  the  method  of  the  operator,  and  is  generally 
attributed  to  faulty  disinfection  of  the  deep  stitches  or  suture  material  or 
undue  suture  pressure.  This  may  be  so,  but  we  are  by  no  means  sure 
that  the  infection  is  not  more  frequently  due  to  incomplete  disinfec- 
tion of  the  slcin  or  some  faulty  manipulation  on  the  part  of  the  surgeon 
or  his  assistants.  However  that  may  be,  suppuration  after  radical 
cure  very  seriously  interferes  with  the  result  of  the  operation.  Separa- 
tion of  the  tissues  takes  place  in  practically  all  cases  in  which  suppura- 
tion occurs  and  the  wound  does  not  heal  until  all  septic  suture  material 
is  absorbed  or  thrown  off.  As  this  may  take  a  long  time,  the  inguinal 
canal  becomes  infiltrated  with  inflammatory  cells  and  converted  into 
cicatricial  tissue  which  yields  gradually  before  the  weight  of  the  ab- 
dominal contents.  Hence  the  sooner  the  septic  stitches  are  removed 
the  better,  and  we  would  advise  that  whenever  the  accident  has  occurred, 
the  wound  should  be  opened  up,  either  by  turning  aside  the  original 
flap  or,  in  some  cases  better,  by  a  second  smaller  incision  over  Pou- 
part's  ligament,  so  as  to  expose  the  lower  end  of  the  deep  stitches,  which 
are  found  and  removed;   in  this  way  much  time  is  saved.     (Cheyne.) 

It  sometimes  happens  that,  long  after  the  wound  has  healed  and 
the  patient  has  been  about,  a  small  vesicle  forms  in  the  scar  and  leaves 
a  sinus  leading  down  to  a  stitch;  this  has  happened  even  many  months 
after  the  operation,  and  the  sinus  will  not  heal  until  the  stitch  concerned 
has  escaped  or  has  been  removed.  The  cause  of  this  is  not  quite  clear. 
It  may  be  some  peculiar  quality  of  silk  or  it  may  be  due  to  some  slow- 
growing  nonpyogenic  organism  introduced  along  with  the  silk  at  the 
operation,  or,  again,  it  is  conceivable  that  the  tissues  around  the  stitch 
become  infected  from  the  blood  at  a  later  period,  when  the  patient's 
resisting  power  is  not  good.  Fortunately,  in  our  experience  at  any 
rate,  this  is  an  excessively  rare  occurrence,  and  need  not  be  taken  into 
consideration.     Various  applications  have  been  suggested  to  prevent 


248  POSTOPERATIVE    TREATMENT. 

stitch  abscess.  Our  hernia  cases  seem  to  do  best  without  overprepa- 
ration.  Just  before  the  operation  a  simple  but  thorough  scrubbing  of 
the  skin  after  the  hair  is  removed  is  all  that  is  requisite.  The  steriliza- 
tion of  the  deeper  surfaces  of  the  skin  is  very  difficult,  if  not  impossible, 
hence  the  application  of  mercurial  ointment,  soap  poultices,  and  all 
such  methods  only  tends  to  increase  the  danger  of  infection,  or  at  least 
favors  dermatitis.  When  we  have  reason  to  believe  that  sepsis  is  al- 
most inevitable  after  careful  preparation  of  the  skin,  a  Murphy  dam 
should  be  applied  to  cover  the  entire  inguinal  region 'and  genitalia,  the 
dam  to  remain  in  position  until  the  sutures  are  inserted  and  tied,  after 
which  it  is  lifted  at  one  end  and  divided  at  or  near  the  points  of  suture. 

According  to  Kelly,  unnecessary  handling  of  the  wound,  rough 
retraction  of  the  skin  edges,  or  prolonged  pressure  with  metal  retractors, 
carelessness  in  checking  bleeding  in  the  wound,  strangulation  by  tying 
the  ligatures  too  tight  or  too  close  together,  all  conduce  to  the  forma- 
tion of  stitch  abscess. 

Of  the  many  plans  adopted  for  the  prevention  of  stitch  abscess,  we 
will  mention  only  that  of  Blondel.  He  makes  as  few  stitches  as  pos- 
sible through  the  skin,  and  before  drawing  them  tight  he  wipes  the 
sutures  and  edges  of  the  wound  with  90  percent  alcohol,  and  sponges 
the  tissues  with  gauze  dipped  in  it.  Each  suture  is  treated  in  the  same 
manner  before  tying,  and  after  the  wound  is  closed  it  is  dusted  with 
xeroform,  iodoform,  or  equal  parts  of  dermatol  and  aristol.  Alcohol 
dries  the  surfaces  better  than  any  other  substance.  Its  effect  on  grease 
is  also  a  factor  in  the  result,  and  it  has  a  coagulating  effect  on  the  serum 
and  thus  favors  cicatrization. 

POSTOPERATIVE  HERNIA. 
General  Considerations. — Postoperative  hernia  is  much  more 
common  than  is  usually  supposed.  It  may  follow  faulty  technic  or 
closure  of  the  abdominal  incision.  In  the  majority  of  instances  it  oc- 
curs in  cases  in  which  drainage  has  been  used.  This  is  because  the 
drain  separates  the  fascial  sheaths  of  the  recti  muscles  and  other  sur- 
faces which  otherwise  would  immediately  unite.  The  small  opening 
thus  made  in  the  wound  increases,  and  hernia  results.  It  is  one  of  the 
most  distressing  sequels,  causing  the  patient  constant  discomfort  when 
erect,  limiting  to  a  great  degree  her  activity,  and  even  endangering  life 
from  incarceration  of  the  bowel  in  the  sac.  It  was  far  more  frequent 
in  the  days  when  the  abdomen  was  habitually  drained  after  the  opera- 


LAPAROTOMY   AND   OPERATIONS    UPON  THE   ABDOMEN,  249 

tion.  "Hernia  is  more  frequent  in  women,  who  become  stouter  after 
operation,  and  in  whom  the  intraabdominal  pressure  is  increased." 
(Kelly.) 

The  Cause  of  Postoperative  Hernia. — In  an  effort  to  ascertain 
the  cause  for  the  development  of  hernia  following  abdominal  opera- 
tions, Wolfe  has  tried  the  various  kinds  of  sutures  and  suture  materials 
as  well  as  different  forms  of  abdominal  binders  after  operation  with- 
out being  able  to  discover  that  they  bear  any  direct  relation  to  this  sub- 
ject. A  careful  study  of  the  histories  of  patients  seemed  to  demon- 
strate that  hernia  occurred  most  frequently  in  the  cases  in  which  pro- 
nounced abdominal  distention  developed  within  the  first  few  days  after 
operation,  regardless  of  the  method  by  which  the  wound  was  closed. 
The  distention  probably  acted  as  a  direct  factor  in  the  production  of 
hernia  by  causing  the  fascial  sutures  to  yield  or  cut  through.  Abdom- 
inal distention  and  abdominal  hernia  developing  shortly  after  opera- 
tion seemingly  stand  in  the  relation  of  cause  and  effect. 

Since  making  these  observations  two  years  ago  the  author  has  closed 
completely  only  those  laparotomy  wounds  in  which  an  absolutely  un- 
complicated course  would  be  expected.  In  all  other  cases,  in  which 
more  or  less  secretion  could  be  expected,  in  which  the  peritoneum 
was  traumatized,  or  in  which  only  a  mild  recent  inflammation  was 
found,  he  introduced  a  small  iodoform  gauze  drain  and  thereby  pre- 
vented postoperative  meteorism.  Since  adopting  the  above  plan  the 
author  is  convinced  that  the  sutures  retain  a  firmer  hold  and  hernia 
develops  less  frequently. 

After  operations  on  hernia  developing  in  the  hnea  alba,  the  intra- 
abdominal pressure  and  the  lateral  traction  of  the  transverse  and  ob- 
lique abdominal  muscles  weaken  the  newly  formed  scar  tissues  and 
favor  a  return  of  the  hernia. 

Of  the  14  cases  of  postoperative  hernia  that  have  come  under  my 
personal  observation,  12  followed  superficial  infection  of  the  abdom- 
inal wound  after  laparotomy,  and  2  followed  prolonged  drainage  in 
appendicular  abscess.  Of  the  12  laparotomy  cases,  the  hernia  oc- 
curred in  the  linea  alba  or  line  of  incision,  follo'v\ing  the  use  of  the 
subcuticular  silver  wire  suture,  and  7  were  found  to  be  devoid  of  the 
peritoneal  covering,  i.  e.,  the  edges  of  the  peritoneum  had  been  widely 
separated,  the  protruding  bowel  being  held  in  position  solely  by  the 
muscles  and  fascia.  In  the  other  cases  (5)  the  peritoneal  sac  was  un- 
usually large. 


250  POSTOPERATIVE    TREATMENT. 

Operations  for  postoperative  hernia  differ  only  from  ordinary 
hernia,  (i)  in  the  removal  of  all  scar  tissue;  (2)  the  redundant  sac  of 
peritoneum,  if  present,  should  be  removed,  and  the  edges  overlapped, 
as  recommended  by  Andrews;  (3)  in  the  absence  of  the  peritoneal 
covering,  the  peritoneum  must  be  found  and  bluntly  freed,  dissected, 
or  loosened  well  back  from  the  adherent  tissues.  The  edges  must  be 
freshened  and  lapped  or  closely  approximated.  This  is  often  a  very 
difi&cult  matter,  and  if  there  is  great  tension  or  difficulty  of  approxi- 
mation, retentive  button  sutures  of  silkworm-gut  passing  through  the 
entire  thickness  of  the  abdominal  walls  should  be  used  as  a  matter 
of  additional  reinforcement.  A  blunt-pointed  round  needle  should  be 
used,  in  the  insertion  of  the  sutures,  and  the  edges  of  the  intermediate, 
subcutaneous,  and  cutaneous  tissues  carefully  freshened  before  closing 
the  incision. 

In  order  to  obtain  a  firmer  scar  at  the  site  of  operation,  Menge 
devised  a  new  method,  which  he  has  employed  in  two  cases  with  very 
satisfactory  results.  The  hernia  is  exposed  by  a  transverse  incision 
and  the  hernial  sac  is  extirpated.  The  anterior  layer  of  the  sheaths 
of  the  recti  muscles  is  then  divided  by  a  transverse  incision  extending 
from  each  side  of  the  hernial  ring  outward  for  a  distance  of  three  centi- 
meters beyond  the  inner  edges  of  the  separated  recti  muscles.  The 
recti  are  then  dissected  free  from  the  anterior  and  posterior  layers  of 
their  sheaths,  care  being  taken  to  avoid  unnecessary  injury  to  the 
bloodvessels.  The  anterior  and  posterior  layers  of  the  sheaths  are  then 
separated  from  one  another  above  and  below  the  hernial  ring,  and  from 
the  recti  muscles  inward  to  the  median  line  by  means  of  the  forefinger. 
In  the  median  line  the  two  layers  are  too  firmly  united  to  permit  of 
their  separation  by  blunt  dissection,  but  this  can  be  accomplished  by 
splitting  them  with  a  knife  for  a  distance  of  three  centimeters  above 
and  below  the  hernia  orifice.  The  posterior  layer  of  the  rectal  sheath 
is  now  sutured  transversely,  the  mobilized  edges  of  the  recti  are  brought 
together  and  sutured  in  a  longitudinal  direction,  the  anterior  sheath 
of  the  recti  is  closed  transversely,  and  the  fat  and  skin  are  united  in 
separate  layers  by  continuous  sutures.  By  this  method  of  forming 
flaps,  longitudinal  pulls  on  the  scar  are  expended  on  the  intact  fibers 
of  the  recti,  lateral  pulls  are  resisted  perfectly  by  the  two  layers  of  the 
sheaths  of  the  recti,  and  a  tendency  to  the  recurrence  of  the  hernia  is 
thereby  greatly  diminished. 


LAPAROTOMY    AND    OPERATIONS    UPON   THE    ABDOMEN.  25 1 

UMBILICAL  HERNIA. 
Postoperative  Treatment  (Mayo's  Method). — In  very  large  pro- 
trusions in  which  part  of  the  hernial  contents  are  irreducible  the  pa- 
tient must  be  kept  in  bed  on  a  reduced  diet  for  several  weeks,  and  di- 
rected to  manipulate  the  hernia  with  the  intention  of  replacing  the  hernia 
as  much  as  possible.  The  irreducible  portion  must  not  be  forced  into 
the  abdominal  cavity  after  losing  the  right  of  habitation.  If  very  fleshy, 
the  hernia  large,  with  a  view  to  the  reduction  of  weight,  the  patients  are 
placed  upon  a  restricted  diet  for  several  weeks;  purgatives  are  fre- 
quently administered  and  the  entire  intestinal  tract  emptied  as  far  as 
possible.  After  the  operation  the  ordinary  dressings  are  applied — 
sometimes  superficial  drainage  for  forty-eight  hours.  The  patients 
are  kept  in  bed  from  three  to  four  weeks  upon  a  light  diet,  and  after 
getting  about  are  not  allowed  to  apply  a  truss,  although  most  of  them 
prefer  to  wear  an  ordinary  abdominal  elastic  supporter  for  a  year. 


CHAPTER   XII. 

OPERATIONS   UPON  THE  UTERUS,  VAGINA, 
BLADDER,  AND  KIDNEYS. 


CHAPTER  XII. 

OPERATIONS    UPON    THE    UTERUS,    VAGINA,    BLADDER, 

AND  KIDNEYS. 

ABDOMINAL  HYSTERECTOMY. 

After-treatment. — -The  finished  operation  of  abdominal  hyster- 
ectomy should  leave  the  peritoneum  of  the  pelvis  completely  closed 
and  the  cervix  representing  the  stump  of  the  operation  well  buried 
beneath  that  serous  membrane.  The  operation  when  completed 
should  show  the  bottom  of  the  pelvis  smooth,  free  from  bleeding  points, 
and  with  the  peritoneum  intact  at  all  places.  The  toilet  of  the  peri- 
toneum and  the  closure  of  the  wound  are  the  last  steps  in  the  opera- 
tion. After  removal  of  all  blood  from  the  bottom  of  the  pelvis  the 
large  gauze  packs  should  be  carefully  removed,  the  intestines  should 
be  replaced  in  the  bottom  of  the  pelvis,  and  omentum  spread  carefully 
over  the  surface  of  the  wound.  The  operation  being  performed  under 
strict  asepsis,  these  patients,  as  a  rule,  recover  rapidly  from  the  opera- 
tion. They  should  be  stimulated  with  normal  salt  infusions  and  by 
strychnin,  and  reaction  established  as  early  as  possible  by  the  applica- 
tion of  dry  heat,  etc.  Retention  of  urine  is  quite  common  after  this 
operation.  Every  effort,  however,  should  be  made  to  have  the  patient 
pass  urine  voluntarily,  the  catheter  being  used  only  under  strict  asep- 
sis as  a  last  resort.  After  the  first  twenty-four  hours  attention  should 
be  given  to  proper  nourishment  of  the  patient,  the  prevention  of  me- 
teorism,  etc.  Further  after-treatment  is  practically  the  same  as  for 
laparotomies  in  general,  to  which  the  reader  is  referred. 

VAGINAL  HYSTERECTOMY. 
After-treatment. — Martin,    who   uses   the   forceps    and   clamp 

method,  states  that  patients  after  a  vaginal  hysterectomy  are  treated 
in  the  same  way  as  after  an  abdominal  incision.  The  one  exception 
to  be  made  is  in  the  management  of  the  bladder.  On  account  of  the 
dressings,  the  patient  should  be  catheterized  until  after  the  forceps 
are  removed.  The  dressings  are  not  disturbed  until  it  becomes  neces- 
sary to  remove  the  forceps,  and  then  only  the  excernal  dressings. 

255 


256  POSTOPERATIVE    TREATMENT. 

The  forceps  are  removed  in  sixty- two  hours  in  the  following  manner : 
The  external  dressings  and  wrappings  are  removed  from  the  handles 
of  the  instruments  and  the  silk  securing  the  handles  is  cut.  Without 
disturbing  the  dressings  any  more  than  is  necessary  the  lock  of  the 
forceps  is  then  opened,  and  the  blades  separated  so  that  the  pressure 
is  taken  off  of  the  tissue  in  the  grasp  of  the  "blades,  but  the  forceps 
are  not  removed  immediately  from  their  location.  The  forceps  of  the 
opposite  side  are  treated  in  the  same  way,  the  blades  being  separated, 
and  then  the  operator  waits  for  at  least  fifteen  minutes,  in  order  to  make 
certain  that  hemostasis  is  secure.  If  for  any  reason  a  rush  of  blood 
occurs  during  the  period  of  waiting,  it  is  only  necessary  to  lock  the 
forceps,  and,  as  they  have  not  been  disturbed,  one  is  very  sure  that  no 
harm  can  come  as  a  result  of  this  relocking.  After  the  end  of  fifteen 
or  twenty  minutes  the  forceps  may  be  carefully  removed,  the  dressings 
cut  off  level  with  the  vulva,  and  an  abundant  supply  of  soft,  fresh, 
perineal  dressings  applied.  Twenty-four  hours  after  the  removal  of 
the  forceps  the  packing  is  removed  from  the  entire  handkerchief. 
Twenty-four  hours  after  this,  vaginal  douches  of  sterile  water  or  boric- 
acid  solution  may  be  employed,  great  care  being  observed  to  keep  the 
reservoir  low  in  order  to  avoid  pressure,  and  also  to  secure  a  good  and 
complete  return  flow  immediately  so  as  to  run  no  risk  of  distending  the 
vagina  and  causing  the  entrance  of  fluid  into  the  abdominal  cavity. 
From  this  time  on  douches  may  be  employed,  and  later  antiseptic 
douches  of  mercuric  chlorid,  or  other  materials,  may  be  used  as 
indicated.  Patients  are  allowed  to  urinate  after  the  forceps  are 
removed,  care  being  maintained  to  renew  the  dressings  after  each 
urination. 

Suture  Method. — Kelly  states  that  when  the  effects  of  the  anes- 
thesia have  worn  off,  it  is  not  necessary  to  keep  the  patient  on  her  back. 
She  will  be  greatly  relieved  from  time  to  time  by  being  gently  turned 
over  on  one  side  or  the  other;  after  a  few  days  she  may  turn  on  her  face 
and  urinate  in  this  posture.  At  first  the  catheter  should  be  used  three 
or  four  times  daily.  The  bowels  should  be  moved  on  the  third  day 
by  a  laxative  pill,  followed  by  a  warm  enema  of  oil  and  soapsuds,  or 
of  glycerin  and  oil,  180  c.c.  (6  ounces).  During  the  evacuation  she 
must  avoid  straining.  If  the  fecal  matter  does  not  easily  pass  out, 
the  nurse  must  assist  with  her  fingers.  After  this,  a  movement  must 
be  secured  every  other  day.  The  diet  during  the  convalescence  should 
consist  for  the  first  two  or  three  days  of  liquids,  followed  by  soft  foods, 


OPERATIONS    UPON   UTERUS,    BLADDER,    KIDNEYS,    ETC.  257 

nourishing  soups,  toast,  soft-boiled  eggs,  oyster  soup,  various  starchy 
foods,  etc. 

Pain  following  the  operation  is  often  entirely  absent  and  is  rarely 
unbearable.  Hypodermatics  of  morphin  should  be  used  sparingly  to 
relieve  severe  pain  during  the  first  tv^enty-four  hours. 

If  the  pack  continues  dry,  and  there  is  no  discharge  from  the  vagina, 
it  may  be  left  there  five  days  longer.  To  remove  the  pack  the  patient 
is  brought  with  the  buttocks  to  the  edge  of  the  bed  with  the  thighs 
flexed.  The  operator  slips  a  narrow  Sims  speculum  into  the  vagina, 
retracting  the  posterior  wall,  and  with  dressing  forceps  draws  the 
strips  of  gauze  out  from  between  the  ligatures.  As  soon  as  the  strips 
are  removed  the  vaginal  vault  must  be  cleansed  with  pledgets  of  ab- 
sorbent cotton,  and  a  fresh  pack  inserted. 

No  vaginal  douches  of  any  kind  should  be  used  until  three  weeks 
have  passed,  when  a  3  percent  warm  carbolized  douche  or  boric-acid 
douche  may  be  given  once  or  twice  daily,  using  a  short  nozle  and  tak- 
ing great  care  not  to  push  it  too  far  in.  When  silk  ligatures  are  used, 
the  discharge  is  sure  to  become  odorous  sooner  or  later,  and  the  vagina 
must  be  cleansed  more  frequently.  The  ligatures  loosen  and  come 
away  with  a  little  traction  in  bunches,  in  from  four  to  six  weeks.  It 
is  a  good  plan  not  to  wait  for  them  to  become  detached,  but  in  the 
course  of  three  weeks  to  expose  and  remove  them  with  forceps  and 
scissors.  These  sutures  can  be  removed  most  easily  with  the  patient 
in  the  knee-breast  or  the  Sims  posture. 

Convalescence. — ^After  "eighteen  days  the  patient  may  sit  in  a 
reclining  chair  a  little  while  each  day,  and  after  this  gradually  increase 
her  movements,  until  after  four  weeks,  when  she  is  usually  able  to  be 
up  all  day.  At  this  time  an  examination  will  show  that  the  vaginal 
vault  is  closed,  and  the  wound  area  has  contracted  down  to  a  trans- 
verse granulating  linear  scar,  with  the  granulations  more  abundant 
at  each  end.  After  six  or  eight  months  this  whole  line  has  contracted 
still  more,  until  it  is  a  thin  white  cicatrix  closing  the  vault. 

After  a  hysterectomy  the  patient  should  avoid  hard  work,  hea^y 
lifting,  and  prolonged  exertion  for  several  months.  Recovery  of  health 
is  usually  rapid;  within  a  few  months  a  pale,  emaciated  woman  often 
regains  all  her  lost  vigor.  But  the  surgeon  still  has  a  duty  to  perform 
in  continuing  to  watch  these  cases,  examining  them  at  first  at  inter- 
vals of  two  or  three  months,  and  later  every  six  months,  in  order  to 
detect  at  once  any  recurrence  of  the  disease.     It  will  occasionally  be 

iS 


258  POSTOPERATIVE    TREATMENT. 

necessary  to  cut  out  a  small  area  of  recrudescence  in  the  vaginal  vault, 
which  will  be  detected  at  an  early  stage  by  this  careful  inspection. 

ALEXANDER'S  OPERATION  FOR  RETROVERSION. 

After-treatment. — Immediately  following  the  operation  the  pa- 
tient is  placed  in  bed,  preferably  in  the  prone  position,  or  if  the  pos- 
terior vaginal  vault  has  been  well  packed  with  gauze  and  the  fundus 
of  the  uterus  held  well  upward,  the  patient  may  be  turned  very  gently 
upon  either  side.  General  restlessness  or  constant  turning  or  changing 
of  the  position  very  frequently  results  in  such  tension  upon  the  tissues 
as  to  cause  stitch  abscess  or  necrosis  of  the  tissues,  with  subsequent 
suppuration,  hence  the  patient  should  be  cautioned  regarding  un- 
necessary movements,  and  morphin  used  for  pain  or  to  enforce  quietude. 
The  operation  is  usually  performed  under  strict  asepsis,  and  healing 
by  first  intention  is  the  usual  result.  The  operation  being  extraperi- 
toneal is  seldom  accompanied  by  serious  complications. 

The  general  treatment  as  to  diet,  etc.,  is  the  same  as  following  a 
simple  herniotomy.  The  stitches  should  be  removed  on  the  ninth 
day,  and  if  there  is  no  suppuration  or  other  evidence  of  sepsis,  should 
be  dressed  in  the  usual  manner.  If  at  any  time  septic  symptoms  are 
manifest,  sufficient  stitches  should  be  removed  to  relieve  tension,  after 
which  the  treatment  is  the  same  as  for  that  of  ordinary  septic  wounds 
heretofore  described. 

TRACHELORRHAPHY. 

After-treatment. — The  following  points  laid  down  by  Emmet 
are  essential  to  proper  healing,  and  necessary  to  secure  satisfactory 
results :  The  cicatricial  plug  in  each  angle  must  be  completely  removed. 
The  strip  of  mucous  membrane  left  in  the  median  line,  which  is  to 
serve  as  the  mucous  lining  of  the  restored  cervical  canal,  must  be  of 
sufficient  width  to  prevent  stenosis.  Sufficient  tissue  should  be  removed 
on  each  side  of  both  lips  to  allow  them  to  come  into  apposition  with- 
out tension.     All  the  sclerosed  tissue  must  be  removed. 

For  about  ten  days  after  the  operation  the  patient  is  kept  in  bed, 
and  not  allowed  even  to  sit  up.  This  may  seem  to  be  unnecessary 
caution,  but  when  we  consider  the  dragging  down  of  the  uterus  which 
occurs  during  the  operation,  this  period  of  rest  seems  only  prudent, 
even  though  the  healing  process  were  proceeding  satisfactorily.     Dur- 


OPKKATJONS    UPON    L'TKRIJS,    I5LAI)I)KR,    KIDNEYS,    ETC.  259 

ing  this  period  caiijolizcd  douches  are  employer!  io  preserve  cleanli- 
ness, the  bowels  are  kept  regular,  anrl  she  is  allowed  to  pass  her  urine 
voluntarily  if  possible.  After  any  operation  the  catheter  should  be 
avoided  as  much  as  possible,  for  its  use  is  very  prone  to  cause  irrita- 
tion of  the  bladder,  which  may  easily  prove  more  annoying  than  the 
operation  itself.  I  do  not  allow  the  catheter  to  be  [massed  by  touch 
alone,  but  insist  that  the  urethra  and  adjoining  jjarts  be  thoroughly 
cleansed  and  then  the  catheter  introduced  by  sight. 

Removal  of  Sutures. — The  usual  custom  is  to  remove  the  sutures 
at  the  end  of  about  ten  days,  but  my  habit  for  some  time  past  has  been 
to  examine  the  patient  with  the  Sims  speculum  at  the  end  of  this  time, 
and  if  the  stitches  do  not  appear  to  be  causing  irritation  or  are  not  in 
danger  of  cutting  through,  they  are  let  alone,  and  the  patient  is  allowed 
first  to  sit  up,  and  then  to  walk  around.  If  she  menstruates  within 
a  short  time,  it  is  best  to  leave  the  stitches  in  until  this  is  past.  After 
this  they  are  removed,  the  vagina  cleansed,  and  a  tampon  of  tannin 
and  iodoform  introduced. 

As  regards  the  manner  of  removing  the  sutures,  it  is  only  necessary 
to  say  that  the  cervix  is  exposed  with  the  Sims  speculum,  and  with 
an  ordinary  uterine  dressing  forceps  the  stitch  farthest  away  from  the 
external  os  is  grasped,  and  the  suture  cut,  care  being  taken  not  to  cut 
off  the  knot,  for  then  it  is  almost  impossible  to  find  the  suture.  If 
the  nearest  suture  is  removed  first,  one  is  likely  to  tear  open  the  cer- 
vix in  removing  the  other  less  accessible  ones.  If  the  upper  ones  are 
removed  first,  and  there  should  be  a  little  oozing,  the  field  of  operation 
is  obscured  by  the  blood.  After  removing  the  stitches  the  sound  is 
introduced  to  be  sure  that  there  is  no  obstruction  in  the  cervical  canal. 
The  fissures  left  by  the  sutures  will  usually  be  obliterated  in  about  a 
week. 

NEPHROTOMY  AND   OPERATIONS   IN   GENERAL  UPON  THE 

KIDNEY. 

In  operations  upon  the  kidney  or  urinary  tract  it  is  usually  ad- 
visable to  place  the  patient  upon  a  course  of  salol  45  grains  or  urotropin 
15  grains  daily  for  several  days  prior  to  the  operation. 

Nephrotomy  can  be  performed  from  the  front  or  behind.  The 
anterior  incision  recommended  by  von  Bergmann  is  generally  kno-mi 
as  the  lateral  incision,  although  the  chief  part  lies  on  the  anterior  aspect 
of  the  abdomen.     For  the  majority  of  cases  of  simple  nephrotomy 


26o  POSTOPERATIVE    TREATMENT. 

the  posterior  oblique  incision,  as  recommended  by  Czerny  and  others, 
may  be  regarded  as  the  normal  incision  in  the  lumbar  region,  as  it 
corresponds  with  the  course  of  the  vessels  and  nerves  and  gives  the 
best  access  to  the  deeper  parts. 

In  nephrorrhaphy  the  thin  fibrous  capsula  propria  of  the  kidney 
is  incised  and  stripped  from  the  organ  so  that  a  good  grip  of  it  may  be 
included  by  the  four  to  six  sutures  which  are  used  to  unite  the  capsule 
to  the  lumbar  fascia.  The  exposed  kidney  substance  lies  at  the  bot- 
tom of  the  wound,  which  is  ordinarily  left  open,  healing  taking  place 
by  granulation  in  order  that  firm  scar  tissue  may  extend  from  the  skin 
to  the  kidney  substance.  In  all  operations  upon  the  kidney  where 
the  substance  of  the  kidney  has  been  interfered  with  it  is  almost  neces- 
sary to  treat  the  wound  by  the  open  method,  not  only  on  account  of 
the  escape  of  urine  or  the  fear  of  a  urinary  fistula  being  formed,  but 
also  for  the  reason  that  the  surrounding  tissues  are  readily  infected. 

If  the  pelvis  of  the  kidney  has  been  opened  or  if  there  is  any  indi- 
cation of  infection,  a  tampon  of  iodoform  or  xeroform  gauze  should  be 
inserted  down  to  the  pelvis  of  the  kidney,  or  a  drainage-tube  inserted, 
after  thoroughly  washing  out  the  pelvis  and  wound  with  sterile  salt 
solution.  If  an  ordinary  drainage-tube  is  used,  it  should  be  surrounded 
with  iodoform  or  xeroform  gauze  and  fixed  in  position  with  a  strip  of 
gauze  and  collodion.  The  outer  dressings  require  to  be  changed  fre- 
quently. 

In  operations  for  nephrorrhaphy  or  fixation  of  the  kidney  it  is  essen- 
tial that  the  cicatrization  which  follows  should  involve  a  considerable 
area  of  the  kidney  substance  itself,  for  it  is  only  in  this  way  that  cer- 
tain and  permanent  fixation  is  possible.  The  endeavor  to  obtain, 
union  by  first  intention  does  not  give  as  satisfactory  results  as  the  open 
method  of  treating  the  wound,  complete  healing  by  granulation  re- 
quiring four  to  six  weeks. 

In  nephrectomy  the  method  of  removing  the  kidney  depends 
upon  the  disease.  If  possible,  the  kidney  should  be  freed  in  toto  after 
all  the  large  vessels  entering  the  capsule  have  been  carefully  ligated  and 
the  structures  at  the  hilus  carefully  isolated.  The  ureter,  which  lies 
lowest,  is  ligated  last,  the  renal  artery  and  vein  being  fixed  firmly  and 
tied.  The  wound  may  now  be  closed,  two  short  glass  tubes  being  in- 
troduced for  twenty-four  to  thirty-six  hours. 

When  suppuration  is  present  or  infective  processes  exist,  the  ureter, 
unless  it  can  be  completely  extirpated,  is  stitched  to  the  wound.     Ex- 


OPERATIONS  UPON   UTERUS,   BLADDER,    KIDNEYS,    ETC.  261 

cision  of  the  ureter  is,  however,  always  preferable,  and  the  w(;und  under 
these  circumstances  should  be  carefully  packed  with  iofloform  gauze 
and  treated  after  the  open  method. 

After  operations  upon  the  kidneys  the  skin  and  bowels  should 
be  kept  very  active  and  the  patient  kept  warm  and  comfortable.  It 
is  essential  that  the  amount  of  urine  passed  should  be  carefully  meas- 
ured, that  any  diminution  in  quantity  may  be  detected  at  once.  Should 
the  skin  around  the  wound  become  inflamed  or  sore  from  the  secre- 
tion of  urine  or  discharge,  sterilized  benzoated  zinc  oxid  ointment 
should  .be  used  freely.  Following  nephrectomy,  pain  is  sometimes 
very  severe,  requiring  the  use  of  morphin  hypodermatically,  but  morphin 
when  used  in  these  cases  should  always  be  combined  with  digitalin 
in  order  to  overcome  the  tendency  toward  diminution  of  urinary  se- 
cretion. A  complication  of  persistent  vomiting,  so  common  after 
operations  upon  the  kidneys,  may  be  overcome  by  some  of  the  methods 
heretofore  mentioned.  A  temperature  of  103°  to  105°  F.  is  not  un- 
common after  nephrectomy  or  operations  upon  the  kidneys.  This 
ordinarily  should  occasion  no  alarm,  being  reflex  in  character  and 
supposed  to  be  due  to  interference  with  or  irritation  of  the  sympathetic 
nerves.  A  subnormal  temperature  followed  by  a  pronounced  rigor  is 
indicative  of  sepsis  and  calls  for  prompt  examination  of  the  wound. 

.  Abscess  of  Kidney. — After  the  evacuation  of  the  pus  and  the 
exploration  of  the  cyst,  the  kidney  should  be  well  flushed  out  with 
warm  sterilized  water;  a  drainage-tube  is  then  introduced  up  to  the 
kidney.  This  is  packed  round  with  gauze,  and  the  parietal  w^ound 
is  closed  around  the  tube. 

In  cases  in  which  the  kidney  is  found  to  be  very  mobile  the  organ 
must  be  steadied  while  the  abscess  cavity  is  being  dealt  with ;  and  be- 
fore the  tube  is  inserted  it  may  be  desirable  to  secure  the  too  movable 
gland  in  place  by  means  of  two  or  more  deep  sutures  introduced  into 
the  renal  tissue.  The  after-treatment  of  these  cases  differs  in  no  es- 
sential from  that  indicated  in  nephrolithotomy.  The  tube  should  be 
shortened  gradually,  the  dressings  must  be  frequently  changed,  and 
the  wound  cavity  be  frequently  and  freely  irrigated. 

OPERATIONS  UPON  THE  BLADDER. 
Preparatory    Treatment. — Before    undertaking     any    operation 
upon  the  bladder  (according  to  Ochsner)  it  is  desirable  that  the  urine 
should  be  as  nearly  aseptic  as  possible.     Measures  should  be  taken 


262  POSTOPERATIVE    TREATMENT. 

to  make  the  urine  as  nearly  normal  as  the  condition  of  the  patient 
will  permit.  The  condition  for  which  the  operation  is  performed 
usually  predisposes  to  an  abnormal  state  of  the  urine,  and  frequently 
not  only  the  bladder  but  also  the  kidneys  are  diseased.  If  the  urine 
contains  septic  material,  this  condition  can  be  changed  by  dilution, 
the  patient  being  given  large  quantities  of  distilled  water,  or,  if  this  is 
not  agreeable,  one  of  the  various  mineral  waters  may  be  given  in  large 
quantities.  This  in  itself  will  reduce  the  septic  nature  of  the  urine  to 
a  great  extent.  If  the  urethra  is  permeable  to  the  passage  of  a  catheter, 
irrigation  of  the  bladder  with  a  mild  nonirritating  antiseptic  solution, 
such  as  a  solution  of  boric  acid,  a  i :  1000  solution  of  permanganate  of 
potash,  a  i :  2000  solution  of  silver  nitrate,  a  saturated  solution  of 
aluminium  acetate,  or  a  solution  of  any  one  of  a  number  of  the  recently 
produced  silver  salts,  may  be  used  to  advantage.  Care  should  be  taken 
not  to  irritate  the  bladder  with  any  of  these  solutions.  If  it  is  found  that 
one  irritates  more  than  the  other,  it  should  be  avoided.  The  bladder 
should  be  filled  moderately  full  and  then  the  fluid  should  be  permitted 
to  escape  again,  or  the  bladder  may  be  irrigated  with  a  constant  stream 
through  a  double  catheter,  one  tube  serving  the  purpose  of  introduc- 
ing the  fluid,  the  other  the  purpose  of  emptying  the  bladder.  A  re- 
peated examination  of  the  urine  will  determine  whether  this  treatment 
reduces  the  amount  of  septic  material  regularly  found. 

There  are  a  number  of  antiseptics  which  can  be  given  internally 
for  the  purpose  of  disinfecting  the  urine.  Of  these,  5-grain  doses 
of  boric  acid  given  with  half  a  pint  of  distilled  water  or  mineral  water 
every  three  hours;  the  same  dose  of  salol,  or  of  urotropin,  or  one- 
grain  doses  of  methylene-blue  given  in  the  same  manner,  are  prob- 
ably the  most  useful.  There  is,  however,  this  fact  to  remember,  that 
urine  usually  is  most  septic  if  the  bladder  is  not  at  any  time  com- 
pletely evacuated,  and  consequently  in  these  cases  but  a  slight  amount 
of  benefit  can  be  expected  unless  this  residual  urine  is  removed  once 
or  twice,  or  oftener,  each  day  and  the  bladder  carefully  irrigated. 

Suprapubic  Cystotomy. — ^After-treatment. — Ochsner  states 
that  the  most  important  point  in  the  after-treatment  of  these  cases 
consists  in  giving  the  patient  large  quantities  of  pure  water  to  drink. 
If  the  patient  is  at  all  shocked  by  the  operation,  it  is  wise  to  give  saline 
transfusion  at  once  or  to  give  an  enema  of  half  a  pint  of  normal  salt 
solution  every  hour.  The  bladder  is  irrigated  with  a  saturated  solu- 
tion of  boric  acid  from  two  to  six  times  a  day,  according  to  the  char- 
acter of  the  urine. 


OPERATIONS   UPON    UTKRUS,    BLADDKR,    KIDNKYS,    KTC.  263 

CoNSii)i':RA'noNS  of  'J'iocunic. — Jf  the  f^pcmlion  has  Ijc-cn  per- 
formed for  the  purpose  of  seeuring  permanent  drainage,  the  incision 
should  be  made  as  near  the  os  pubis  as  possible,  and  should  be  only 
just  large  enough  for  the  ])urp()se  of  permitting  careful  digital  explora- 
tion. Several  purse-string  sutures  should  then  be  applied  in  order  to 
prevent  leakage,  and  a  retention  catheter  introduced.  The  wound 
should  be  tamponed  around  this  retention  catheter  and  the  stitches 
in  the  bladder  wall  should  be  passed  through  the  edge  of  the  wounrl 
and  tied  just  sufficiently  tight  to  hold  the  anterior  wall  in  close  apj^osi- 
tion  with  the  abdominal  wall.  A  few  silkworm-gut  sutures  are  then 
applied,  so  as  to  grasp  the  wound  on  each  side,  and  to  take  a  small 
bite  in  the  anterior  wall  of  the  bladder  above  the  point  of  incision,  and 
two  small  bites,  one  on  each  side  of  the  incision  in  this  portion  of  the 
bladder.  These  sutures  are  left  untied  until  the  first  dressing,  which 
occurs  a  few  days  after  the  operation,  when  the  gauze  tampon  and 
the  three  first  stitches  may  be  removed  and  the  silkworm  sutures  may  be 
tied,  leaving  only  a  space  through  which  the  drainage-tube  passes.  If 
the  bladder  has  been  in  a  septic  condition,  it  is  often  best  to  pass  two 
ordinary  rubber  drainage-tubes,  one-half  a  centimeter  in  diameter, 
perforated  with  several  small  openings  in  the  end,  and  these  two  rub- 
ber tubes  should  be  sufficiently  long  for  the  ends  to  project  into  an 
antiseptic  solution  in  a  bottle  tied  to  the  side  of  the  bed.  It  is  then 
possible  to  irrigate  the  bladder  by  permitting  the  fluid  to  flow  in  through 
one  of  these  tubes  and  out  of  the  other;  and  in  case  one  or  the  other 
becomes  occluded  with  mucus  or  blood,  the  free  one  will  suffice  to 
drain  the  bladder.  It  is  a  good  plan  to  insert  a  glass  tube  into  the 
end  of  the  rubber  tube,  so  that  its  weight  will  keep  it  from  becoming 
dislodged  from  the  bottle.  If  the  presence  of  the  rubber  tubes  gives 
rise  to  pain,  their  position  should  be  changed  occasionally.  (See  Fig. 
69.) 

If  the  operation  is  performed  for  the  removal  of  a  stone  from  a  healthy 
bladder  containing  nearly  normal  acid  urine,  the  wound  in  the  bladder 
may  be  closed  by  a  double  row  of  catgut  sutures,  which  are  not  per- 
mitted to  penetrate  the  mucous  membrane,  however.  The  space  be- 
tween the  bladder  and  the  abdominal  wall  should  always  be  dramed 
thoroughly  in  these  cases  for  fear  of  extravasation  of  urine.  A  soft- 
rubber  retention  catheter  is  placed  into  the  bladder  through  the  ure- 
thra in  such  instances  and  carefully  fastened  in  place,  so  as  to  keep 
the  bladder  thoroughly  drained.     If  there  is  any  doubt  about  the  asep- 


264 


POSTOPERATIVE    TREATMENT. 


tic  condition  of  the  bladder,  it  does  not  seem  wise  to  close  the  bladder 
wall  completely,  in  which  case  the  wound  is  treated  after  the  open 
method,  with  fresh  gauze  packing  daily,  and  healed  from  the  bottom 
by  granulation.   -, 

Senn  advises  two  stages  in  the  operation  in  cases  of  septic  cystitis: 
After  the  anterior  wall  of  the  bladder  has  been  exposed  and  all  hemor- 
rhage arrested,  the  wound  is  packed  with  iodoform  gauze  and  the  dress- 
ing held  in  place  by  strips  of  adhesive  plaster;  this  dressing  is  allowed 
to  remain  for  five  days;   at  the  end  of  this  time  the  wound,  if  it  has 


Fig.  69. — Suprapubic  Drainage.     Tube  in  Situ. 


remained  aseptic,  is  covered  with  a  layer  of  healthy  granulations, 
which  have  closed  the  connective-tissue  channels  and  have  shut  out 
from  the  wound  the  remainder  of  the  prevesical  space.  As  a  second 
stage,  with  the  danger  of  infiltration  lessened  by  these  favorable  cir- 
cumstances, the  bladder  is  incisied  and  drained  in  the  usual  manner; 
under  this  operation  cocain  is  adequate  without  general  anesthesia. 
In  relation  to  this  modification  of  suprapubic  cystotomy  Senn  makes 
the  following  statements: 

"  (i)  Necrosis  and  phlegmonous  inflammations  of  the  margins  of 
the  wound  and  the  tissues  in  the  prevesical  space  (cavum  Retzii)  not 


OPERATIONS    UPON   UTERUS,    BLADDER,    KIDNEYS,   ETC.  265 

infrequently  occur  as  complications  of  suprapubic  cystotomy  if  the 
operation  is  performed  for  affections  complicated  by  septic  cystitis. 
(2)  Suprapubic  cystotomy  in  two  stages  greatly  diminishes,  if  it  does 
not  entirely  overcome,  this  source  of  danger.  (3)  In  the  first  opera- 
tion the  bladder  is  freely  exposed  in  the  usual  manner,  when  the  pre- 
vesical fat  is  dissected  away  over  a  vertical  oval  space  at  a  point  corre- 
sponding to  the  location  of  the  proposed  visceral  incision,  after  which 
the  wound  is  packed  with  iodoform  gauze  and  the  external  dressing 
is  applied  in  such  a  manner  that  it  cannot  be  displaced.  (4)  The 
incision  in  the  bladder  and  the  intravesical  operation  are  postponed 
until  the  external  wound  has  become  covered  with  a  layer  of  active 
granulations,  which  usually  requires  from  four  to  six  days.  (5)  The 
second  operation  can  be  performed  with  the  aid  of  cocain  without 
general  anesthesia.  (6)  This  modification  of  suprapubic  cystotomy 
diminishes  the  immediate  risks  of  the  operation  and  affords  protection 
against  a  number  of  serious  postoperative  complications." 

After-treatment. — (Method  of  Sir  Frederick  Treves.)  If  the 
wound  in  the  bladder  has  been  closed  by  sutures,  the  after-treatment 
of  the  case  is  conducted  upon  the  lines  observed  after  any  ordinary 
abdominal  section.  The  employment  of  the  catheter,  if  the  patient 
cannot  pass  urine,  is  imperative.  A  soft  catheter  should  be  introduced  as 
often  as  required.  The  superficial  sutures  may  be  removed  at  the  end  of 
a  week;  and  if  all  goes  well,  the  patient  may  be  sitting  up  in  ten  days. 

If  the  wound  in  the  bladder  has  been  left  open,  the  after-treatment 
becomes  very  tedious,  and  demands  infinite  care.  The  bed  must  be 
protected  by  mackintosh  sheets,  placed  beneath  the  usual  draw-sheets. 
A  large  cradle  is  spread  across  the  pelvis.  The  care  of  the  wound 
will  demand  the  constant  and  undivided  attention  of  a  nurse. 

The  skin  of  the  perineum,  buttocks,  and  lower  part  of  the  abdomen 
should  be  kept  as  dry  as  possible,  and  should  be  smeared  with  vaselin 
to  prevent  the  irritating  effects  of  the  contact  of  urine.  Over  the 
wound  should  be  placed  a  large  sponge,  and  above  the  sponge  should 
be  a  large  pad  of  absorbent  wool,  applied  transversely,  like  a  scarf, 
from  one  side  of  the  groin  to  the  other.  This  pad  rests  upon  the  pubes. 
It  keeps  the  sponge  in  place,  and  serves  to  absorb  any  urine  which  may 
escape  the  sponge.  It  may  be  conveniently  replaced  by  pads  of  cyanid 
gauze,  frequently  changed.  Not  less  than  20  sponges  should  be  in 
use.  The  arrangement  of  the  bed-clothes  over  the  cradle  allows  the 
part  to  be  always  in  view,  the  patient's  trunk  and  limbs  being  well 
covered   up   with  blankets. 


266 


POSTOPERATIVE    TREATMENT. 


Fig.    70.  —  Stevenson's    Suprapubic 
Drainage-tube. — {Da  Costa.) 


The  sponges  and  wool-pad  must  be  changed  as  often  as  needed — 

possibly  two,  three,  or  four  times  in  the  hour.     The  pad  is,  of  course, 

thrown  away,  but  the  sponge  may 
be  used  over  and  over  again.  Each 
sponge  is  well  rinsed  in  water,  is  then 
immersed  for  some  hours  in  carbolic 
lotion,  is  once  more  rinsed,  and  is 
then  dried  ready  for  use.  Before  each 
sponge  and  scarf  of  wool  are  applied, 
the  skin  should  be  rapidly  dried. 
No  bandage  is  required.  The  patient 
must  lie    upon  the  back,  and  should 

assume,  as  soon  as  he  is  able,  the  sitting  position.     If  he  wishes  to  lie 

upon  one  or  the  other  side, 

the    sponge  and   the   wool 

pad  must    be   adjusted   to 

meet  the  altered  position. 
If   this   plan   is  carried 

out  by  intelligent  and  pains- 
taking nurses,  the  patient's 

bed  may  be  kept  absolutely 

dry,  and  the  skin  perfectly 

sound  and  free  from  excoria- 
tion.    The  sponges  can  be 

changed  during  sleep  with- 
out waking  the  patient,  the 

wound     being     always     in 

view  through  a  "window" 

in  the  cradle.     The  sooner 

the  patient  can  sit  up  in  bed, 

the  better,  as  the  wound  is 

much   more   readily    dealt 

with  when  that  attitude  is 

assumed.     Any  "dressing" 

secured     with     a    bandage     '^^'^-  7-'^- — Stevenson's  Suprapubic  Drainage-tube 

°  in  Place  and    Attached  to    a   Receptacle 

round  the  body    is    useless.  for  Urine.— (Da  Costa.) 

By  the  time  the  dressing  has 

been   applied   and   the  bandage   secured,    the  whole  arrangement  is 


OPERATIONS    UPON    UTERUS,    BLADDICR,    KIDNKYS,    ETC  267 

probably  soaked  with  urine.  The  bladder  may,  when  necessary,  be 
washed  out  with  a  Ijoric-acid  solution  as  often  as  occasion  arises. 

Temporary  Drainage. — A  convenient  form,  if  there  is  not  too 
much  pus  in  the  urine  is  provided  by  anchoring  two  large  soft  rubber 
catheters  together  by  suture  through  the  eyelets,  ])assing  the  rlouble 
tube  thus  formed  through  the  suprapubic  wound  and  into  the  bladder. 
Each  of  these  is  connected  to  a  rubber  tube  by  means  of  a  glass  coupler. 
The  tubes  lead  into  a  basin  beneath  the  patient's  bed.  The  advantage 
of  this  apparatus  is  that  if  one  tube  becomes  blocked,  the  other  will 
drain  the  bladder,  and  also  irrigating  fluid  may  be  passed  through 
one  tube  and  the  other  will  drain  the  fluid  away. 

The  bladder  wound  usually  closes  in  two,  three,  or  four  weeks,  and 
the  external  wound  one  or  two  weeks  later.  It  is  probable  that  the 
patient  will  be  able  to  be  moved  into  a  chair  by  the  end  of  the  second 
or  commencement  of  the  third  week. 

According  to  A.  B.  Craig,  of  Philadelphia,  when  permanent  su- 
prapubic drainage  is  necessary,  one  of  the  best  forms  of  apparatus  for 
this  purpose  is  seen  in  Figs.  70  and  71. 

LITHOLAPAXY. 

After-treatment,  according  to  Dennis,  consists  in  rest  in  bed,  milk 
diet,  and  moderate  doses  of  quinin,  salol,  or  boric  acid.  The  average 
stay  in  the  hospital  after  litholapaxy  in  adults  is  about  ten  days.  Even 
calculi  of  large  size  are  at  the  present  day  treated  by  litholapaxy. 
Buckston-Browne  has  on  several  occasions  crushed  uric-acid  calculi 
weighing  over  three  ounces,  and  also  reports  crushing  a  cystin  calculus 
weighing  two  and  a  quarter  ounces;  such  a  weight  of  cystin  indicates 
a  calculus  of  large  size,  as  cystin  is  a  light  substance. 

Keegan,  after  reporting  50  cases,  which  bring  his  total  up  to  175, 
with  5  deaths,  lays  down  the  following  rules  to  guide  the  inexperienced 
in  performing  the  operation  of  litholapaxy  in  boys :  The  surgeon  should 
be  provided  with  an  ample  supply  of  perfectly  reliable  lithotrites,  all 
of  the  completely  fenestrated  pattern,  and  with  cannulas  with  ser\ice- 
able  stylets.  He  should  never  withdraw^  a  cannula  from  the  bladder 
nor  introduce  one  unless  it  is  fitted  with  a  stylet.  Four  ounces  (124 
grams)  of  water  should  be  the  maximum  quantity  allowed  to  be  in  the 
bladder  at  any  given  moment.  The  aspirator  should  be  used  gently 
and  methodically,  and  water  should  not  be  injected  into  the  bladder 
while  the  patient  strains.     Extreme  gentleness-  and  care  are  essential 


268       "  POSTOPERATIVE    TREATMENT. 

in  practising  all  manipulations  of  instruments  in  the  bladder  and  ure- 
thra. The  operator  should  not  be  in  a  hurry  to  finish  the  operation, 
and  if  possible  he  should  not  leave  a  grain  of  debris  behind  in  the  bladder. 
If  all  these  coijditions  be  fulfilled,  a  large  measure  of  success  will  be 
obtained. 

Guyon  in  his  last  49  cases  of  lithotrity  has  used  a  retained  catheter, 
keeping  it  in  place  for  twenty-four  hours.  In  40  of  these  cases  there 
was  absolute  apyrexia,  and  in  the  other  9  merely  a  slight  and  transitory 
elevation  of  temperature.  Of  the  patients,  27  had  old  phosphatic  cal- 
culi, were  obliged  to  empty  the  bladder  by  catheterism,  and  had  been 
infected  for  a  long  time.  Guyon  remarks  that,  even  admitting  that 
fever  and  cystitis  are  rare  after  lithotrity  at  the  present  day,  this  ex- 
perience demonstrates  that  the  retained  catheter  may  be  employed  with- 
out causing  vesical  inflammation,  as  formerly  thought  to  be  an  invariable 
consequence.  My  own  experience  would  not  lead  me  to  think  it  neces- 
sary in  the  majority  of  cases,  but  his  testimony  would  lead  me  hence- 
forth to  employ  a  retained  catheter  after  litholapaxy  in  old  persons  with 
infected  and  atonic  bladders  and  with  enlarged  prostate. 

Sir  Henry  Thompson's  Method  of  After-treatment. — The  pa- 
tient must  lie  in  bed.  An  india-rubber  hot- water  bottle  or  warm  fomen- 
tations may  be  applied  to  the  hypogastrium.  Some  opium  may  be 
required.  There  may  be  some  urethral  fever,  or  retention  of  urine 
from  atony  of  the  bladder.  Not  infrequently  subacute  cystitis  appears 
on  the  fourth  or  fifth  day.  The  administration  of  urotropin  or  cys- 
tamin  in  5 -grain  doses  and  the  injection  into  the  bladder  of  a  few 
ounces  of  solution  of  silver  nitrate  (half  to  one  grain  to  the  ounce)  are 
useful  for  this  complication.  The  patient  should  be  kept  on  a  light 
or  milk  diet,  and  remain  in  bed  until  any  cystitis  has  subsided.  If 
the  stone  is  small  and  there  have  been  renal  symptoms,  the  opportunity 
should  be  taken  to  exclude  the  existence  of  other  calculi  in  either  kid- 
ney by  skiagraphy.  A  warm  hip-bath  daily  adds  greatly  to  the  patient's 
comfort.  The  urine  contains  no  trace  of  blood,  as  a  rule,  after  the 
second  to  the  fourth  day;  and  in  the  majority  of  cases  the  patient 
may  be  allowed  to  get  up  on  the  seventh  day.  An  occasional  and 
troublesome  complication,  occurring  especially  in  adults,  is  orchitis  or 
epididymitis. 

According  to  Freyer,*  the  average  number  of  days  spent  in  hospital 

*  "Brit.  Med.  Jour.,"  May  9,  1891. 


OPERATIONS    UPON   UTICRUS,    BLADDER,    KIDNEYS,    ETC.  269 

or  under  treatment  is,  in  adult  males,  six;  in  Ixjys,  five  and  a  half;  and 
in  females,  four. 

Results. — Sir  Henry  Thompson's  cases  of  lithotrity  since  1878 
number  378,  including  325  treated  each  at  one  sitting.  The  mortality 
is  a  little  over  3.5  percent.* 

Cadge  expresses  his  belief  that  the  relapses  after  simple  lithotrity 
reach  to  nearly  20  percent,  if  the  cases  of  phosphatic  deposits  and  con- 
cretions common  after  this  operation  are  included  among  the  examples 
of  recurrence  of  the  stone.  Litholapaxy  is  attended  with  no  such 
proportion  of  unsatisfactory  results;  and,  indeed,  if  the  evacuator 
be  carefully  and  thoroughly  employed,  the  relapses  after  litholapaxy 
will  probably  include  no  cases  of  recurrence  due  to  the  actual  retention 
and  subsequent  increase  of  a  fragment. 

PERINEAL  LITHOTOMY. 

Dennis  states  that  when  the  calculus  has  been  extracted  and  the 
bladder  has  been  explored  for  other  chance  calcareous  deposits  adher- 
ing to  the  walls,  or  for  other  concretions,  the  bladder  should  be 
thoroughly  irrigated  with  moderately  hot  water  to  wash  out  any  clots 
of  blood  which  may  have  entered  it,  and  also  to  stop  any  slight  oozing 
from  the  edges  of  the  wound.  If  the  hemorrhage  be  considerable  and 
the  vessels  cannot  be  ligated,  the  air-tampon  or  catheter  en  chemise 
should  be  inserted.  The  packing  which  is  inserted  within  the  cuff  of 
the  latter  instrument  may  be  removed  at  the  end  of  two  or  three  da)'s. 
W.  A.  Mackay  reports  favorably  on  the  use  of  glass  tubes  for  drainage 
after  perineal  or  suprapubic  lithotomy  associated  with  cystitis.  To 
the  end  of  the  glass  tube  a  soft-rubber  tube  is  attached,  and  conveys 
the  urine  to  a  vessel  beneath  the  bed,  in  which  the  end  of  the  rubber 
tube  is  kept  constantly  submerged  in  an  antiseptic  fluid.  The  glass 
tubes  should  be  slightly  smaller  in  caliber  than  those  ordinarily  used 
in  abdominal  sections.  No  other  dressing  is  used  except  light  packing 
around  the  tube  and  a  T-bandage  in  perineal  cases.  Drainage  should 
be  maintained  until  the  urine  becomes  clear. 

When  prolonged  drainage  is  not  deemed  necessary  and  the  hemor- 
rhage is  not  sufficient  to  demand  packing  the  wound,  then  only  a  light 
pad  of  iodoform  gauze  should  be  applied,  but  not  pressed  in  so  tightly 
as  to  prevent  the  free  escape  of  urine  through  the  wound,  which  will 

*"Med.-Chir.  Trans.,"  iSgo. 


270 


POSTOPERATIVE    TREATMENT. 


continue  for  a  day  or  so,  and  then,  owing  to  the  inflammatory  swelHng, 
gradually  cease. 

After-treatment. — The  patient  is  placed  on  a  narrow  bed  with  a 
firm  horsehair  mattress,  protected  by  a  waterproof  sheet.  Beneath 
the  buttocks  are  kept  squares  of  old  sheeting,  which  can  be  changed 
as  often  as  they  are  wet  with  urine.  In  addition  to  the  sheets,  large 
sponges  may  be  employed  to  absorb  the  escaping  urine.  They  can 
be  readily  changed  without  disturbing  the  patient,  they  are  easily 
cleansed,  and  if  plenty  are  employed,  and  each  one  is  allowed  to  lie  for 
some  time  in  a  carbolic  solution  before  it  is  used  again,  the  same  sponges 
ean  be  employed  over  and  over  again.  They  need  to  be  well  dried  by 
heat  before  being  applied,  and  may  be  dusted  with  iodoform. 


Fig.  72. — Lateral  Lithotomy  with  a  Curved  Staff. — {Bryant.) 

A  rope  and  handle-bar  suspended  above  the  bed  will  enable  the 
patient  to  raise  his  pelvis  readily  when  the  squares  of  sheeting  are 
changed.  The  knees  should  be  supported  by  separate  pillows,  with 
an  interval  between  them.  Nothing  must  obstruct  the  free  exposure 
of  the  tube.  Clots  in  the  tube  may  be  removed  with  a  moistened 
feather.  If  the  escape  of  urine  ceases  and  there  is  pain  about  the  blad- 
der, the  tube  may  be  pushed  a  little  further  in,  or  a  soft-rubber  catheter 
may  be  introduced  through  it  into  the  bladder.  In  most  cases  the  tube 
may  be  removed  in  thirty-six  or  forty-eight  hours.  In  some  few  in- 
stances— especially  when  there  have  been  difficulties  of  micturition 
previous  to  the  operation — the  tube  may  have  to  be  retained  for  three 
or  four  days  or  even  longer. 


OPERATIONS    UJ'ON    UTKRUS,    HLADDKK,    KIDNEYS,    ETC.  27/ 

The  parts  exposed  to  the  contact  of  urine  shouhl  Ijc  dried  as  fre- 
c|ucntly  as  is  possible.  The  scrotum  should  !;(■  kept  away  from  the 
perineum  by  a  simple  suspender  or  "crutch  pad."  When  the  urine 
is  alkaline  and  irritating,  the  skin  of  the  buttocks  and  perineum  should 
be  smeared  well  with  vaselin  after  each  change  of  sheets  or  sponges. 
In  cases  of  actually  putrid  urine  the  bladder  should  be  washed  out  two 
or  three  times  a  day  with  a  warm  solution  of  boric  acid.  The  urine 
begins  to  flow  by  the  urethra,  as  a  rule,  between  the  eighth  and  twelfth 
day,  and  the  perineal  wound  is  generally  healed  and  the  patient  "cured" 
within  four  to  six  weeks.  The  same  care  in  the  diet  is  observed  as  is 
customary  after  all  major  operations.  If  the  bowels  are  not  opened 
by  the  third  day,  a  laxative  should  be  given. 

When  secondary  bleeding  occurs,  the  patient  should  be  placed  once 
more  in  the  lithotomy  position,  and  the  wound  thoroughly  cleansed 
and  examined.  The  tube  should  be  removed,  and  the  clots  washed 
out  of  the  bladder. 

When  the  incision  has  been  dried,  it  is  possible  that  the  bleeding 
point  may  be  detected,  especially  if  the  perineum  be  in  a  good  light 
and  the  wound  margins  be  well  retracted.  In  such  a  case  pressure 
forceps  will  meet  the  complication.  Failing  the  easy  securing  of  the 
divided  vessel,  cold  injections  may  be  tried;  but  if  they  fail,  as  is  most 
probable,  the  tube  should  be  reinserted,  and  the  wound  plugged  with 
gauze.  Injections  of  powerful  styptics,  and  especially  of  perchlorid 
of  iron,  are  to  be  absolutely  condemned. 

Complications. — The  following  complications  may  occur  during 
the  after-treatment:  Retention  of  urine  from  blocking  or  displacement 
of  the  tube.  Suppression  of  urine  in  cases  in  which  the  kidneys  are 
diseased.  Incrustation  of  the  wound  with  phosphates  may  occur 
when  the  urine  is  ammoniacal  and  there  is  much  cystitis.  This  is 
especially  met  in  aged  and  feeble  patients.  The  condition  is  met  by 
frequent  irrigation  of  the  bladder  with  boric-acid  lotion  or  mildly 
acidulated  solutions,  and  by  constant  attention  to  the  wound.  Epi- 
didymitis is  not  infrequently  met  after  lateral  lithotomy.  Cellulitis 
from  urinary  infiltration  is,  of  all  the  possible  complications,  one  of 
the  most  serious.     It  is  fortunately  uncommon. 

PERINEORRHAPHY. 
After-treatment  (Martin). — ^After  the  operation  the  patient  must 
lie  in  bed  until  the  wound  is  sound  and  the  sutures  are  all  removed. 


272 


POSTOPERATIVE    TREATMENT. 


This  will  represent  a  period  of  from  fourteen  to  twenty-one  days.     The 
patient  should  be  encouraged  to  lie  upon  the  side.     A  cradle  should  be 


Fig.  73. — Suture  of  Perineum  after  Martin's  Method. — {By  permission.) 

placed  over  the  pelvis,  the  space  under  the  bed-clothes  should  be  venti- 
lated, and  every  opportunity  be  taken  to  change  the  heated  and  close 
atmosphere  with  which  the  wound  must  of  necessity  be  surrounded. 


OPERATIONS    UPON   UTERUS,    BLAVDl.U,    KIDNEYS,    ETC.  273 

It  is  never  ncccs.sary  to  tie  the  legs  together,  as  was  the    barbarous 
and  senseless  custom  at.  one  period.     No  T-bandage  is  rcfjuired.     The 


Fig.    74.— Complete  Closure  of  Perineum,  showlng  Buried   Suture  Knots.— 

(Martin,  by  permission.) 

wound  is  best  dressed  with  iodoform.     This  may  be  hberally  dusted 
over  the  part,  the  wound  being  left  otherwise  uncovered;   or  a  "sani- 

19 


2  74  POSTOPERATIVE    TREATMENT. 

tary  towel"  well  treated  with  iodoform  may  be  worn,  and  the  wound 
be  supported  by  the  soft  pad  of  the  "towel."  The  part  should  be 
kept  throughout  as  dry  as  possible.  Some  patients  suffer  excruciat- 
ingly after  these  ^operations — much  more  so,  as  a  rule,  than  after  ordi- 
nary laparotomies.  Hypodermatics  of  morphin  are  frequently  indis- 
pensable, but  should  be  avoided  when  possible.  Great  difficulty  with 
the  bowels  may  result  from  the  too  free  use  of  the  drug. 

Catheterizing  the  Patient. — Almost  any  patient,  if  properly  en- 
couraged, will  be  able  to  urinate  without  the  use  of  the  catheter,  and 
clean  urine  will  be  less  harmful  to  the  perineum  than  the  indiscrim- 
inate use  of  the  catheter  will  be  to  the  urethra.  The  patients,  there- 
fore, are  requested  to  urinate,  first  removing  the  dressings  from  the 
perineum  before  the  attempt  is  made,  and  the  nurse  is  instructed  to 
irrigate  the  perineum  immediately  after  the  urination  with  a  saturated 
solution  of  boric  acid,  normal  salt  solution,  or  even  sterilized  water. 

Attention  to  the  Bowels. — All  patients  should  be  prepared,  prior 
to  the  operation,  by  a  thorough  evacuation  of  the  intestinal  canal.  They 
are  kept  upon  liquid  food  for  at  least  two  days  before  the  operation.  The 
intestinal  tract  is  rendered  as  aseptic  as  it  is  possible  to  make  it. 
Twenty-four  hours  after  the  operation  laxatives  should  be  administered, 
assisted,  if  necessary,  by  mild  stimulating  enemas.  No  attempt  to  estab- 
lish constipation  should  be  made;  the  bowels  should  move  naturally 
from  the  first. 

Care  of  the  Perineum. — Besides  dressing  the  perineum  with  pads 
of  fluffy,  sterilized  gauze  after  each  urination  of  the  patient  or  move- 
ment of  her  bowels,  the  perineum  is,  as  indicated  before,  irrigated 
several  times  a  day  and  the  dressings  replaced. 

A  note  must  be  made  at  the  time  of  the  operation  of  the  number 
of  sutures  inserted,  as  it  is  not  uncommon  to  lind,  when  weeks  have 
elapsed,  that  a  suture  has  been  overlooked. 

As  the  sutures  are  of  silkworm-gut,  it  is  necessary  that  they  be 
removed,  and  their  removal  is  accomplished  on  the  twelfth  day  after 
the  operation.  As  the  sutures  are  tied  just  within  the  skin-margin, 
the  operator  will  find  that  the  knots,  after  complete  union  has  occurred, 
are  buried  beneath  the  skin.  The  removal  of  the  sutures,  therefore, 
is  a  point  requiring  considerable  delicacy  of  treatment.  After  the  su- 
tures are  separated  and  identified,  one  end  of  the  stitch  is  grasped 
and  gently  drawn  upon  until  the  knot  is  brought  through  the  opening 
made  by  the  single  suture.     Then,  by  cutting  beneath  the  knot  on  one 


OPERATIONS    UPON    IJTKRIIS,    ]}LADI)KR,    KfONEYS,    ETC.     "         275 

side,  the  suture  is  easily  withdrawn.  It  is  well  to  remember  this  in- 
junction, as  it  is  a  very  difficult  and  painful  jjroccdure  to  attempt  to 
cut  beneath  the  knot  unless  it  has  been  drawn  through  the  skin. 

In  the  case  of  the  complete  operation,  the  perineal  sutures  are  re- 
moved first,  and  the  rectal  sutures  at  a  lalcr  ])criod.  'J'he  removal 
is  in  the  reverse  order  to  the  introduction.  A  small  rectal  speculum  will 
probably  be  required  when  the  rectal  stitches  are  taken  out. 

The  patient  should  be  allowed  to  sit  up  on  the  fifteenth  to  the  seven- 
teenth day,  and  gradually  to  get  about  at  the  end  of  the  third  or  the  be- 
ginning of  the  fourth  week.  All  patients  should  be  instructed  to  use 
considerable  care  to  avoid  heavy  physical  work  for  several  months. 


CHAPTER   XIII. 

OPERATIONS  UPON  THE  RECTUM,  PROSTATE 
GLAND,  URETHRA,  AND  SCROTUM. 


(:iiAi''ri':R  xui. 

OPERATIONS    UPON    THE    RECTUM,    PROSTATE    GLAND, 
URETHRA,  AND  SCROTUM. 

HEMORRHOIDS. 

The  postoperative  treatment  depends  largely  upon  the  methc^d 
employed  for  the  removal  of  the  hemorrhoids.  The  ligature  has  been 
for  many  years  the  most  popular  method  among  surgeons  for  the  treat- 
ment of  hemorrhoids.  It  is  perhaps  to  Allingham,  Matthew,  and 
Ricketts  that  this  operation  owes  its  great  popularity.  It  is  applicable 
to  almost  every  variety.  Many  American  surgeons,  however,  prefer 
the  clamp  and  cautery  method.  Whitehead's  method  of  total  excision, 
or  Earle's  modification  of  the  Whitehead  operation,  the  Pratt  or  so- 
called  American  operation,  are  likewise  popular. 

Preparation  of  the  Patient. — In  order  to  obtain  the  best  results 
from  any  of  the  forms  of  operation,  the  patient  should  be  as  carefully 
prepared  as  for  laparotomy.  Thirty-six  hours  before  the  operation  the 
bowels  should  be  thoroughly  emptied  and  the  patient  placed  upon  a 
very  light  diet.  The  evening  before  the  operation,  after  the  parts  have 
been  carefully  shaved  to  the  anus  and  perineum,  a  mercuric  chlorid 
dressing  should  be  applied  and  retained  by  a  T-bandage.  No  purga- 
tive or  injection  should  be  given  the  night  before  the  operation;  on  the 
contrary,  the  patient  should  have  a  quiet,  restful  night.  No  enema 
should  be  given  the  morning  of  the  operation,  but  after  the  patient  is 
anesthetized  the  sphincters  should  be  dilated  and  the  rectum  thor- 
oughly irrigated  with  a  i :  3000  mercuric  chlorid  solution  and  the 
external  parts  made  surgically  clean  with  soap  and  water,  followed  by 
the  mercuric  chlorid  solution,  and,  lastly,  alcohol.  The  bladder 
should  also  be  emptied  before  beginning  any  operation,  and  this 
should  be  done  before  cleansing  the  operative  field. 

Postoperative  Treatment  of  the  Ligature  Method. — ^AEingham 
attributes  all  the  unfortunate  results  which  follow  this  method  to  the 
faulty  after-treatment.  For  the  prevention  of  complications  he  lays 
down  the  following  rules:  He  confines  the  bowels  for  four  or  five  days, 
using  opiuni  or  morphin  freely  for  this  purpose,  and  for  the  relief  of 

279 


28o     ,  POSTOPERATIVE    TREATMENT. 

pain.  On  the  day  following  the  operation  the  outside  dressings  are 
removed.  The  parts  are  dusted  with  iodoform  or  some  such  powder, 
and  after  this  only  small  pledgets  of  dry  gauze  will  be  necessary.  To 
many  patients  a  dressing  moistened  with  a  mild  antiseptic  solution, 
if  applied  hot,  is  more  grateful.  The  bowels  are  moved,  accord- 
ing to  the  necessity  of  the  case,  after  four  or  five  days.  Whatever 
laxative  is  selected  is  given  in  sufficient  dose  to  compel  movement  of 
the  bowels,  even  against  the  patient's  resistance,  for  at  this  time  the 
sphincter  will  have  regained  its  tonicity,  and  the  fear  of  pain  will  cause 
the  patient  to  hold  the  movement  back  as  long  as  possible.  The  best 
laxative  is  one-half  to  one  ounce  of  castor  oil,  administered  in  two  to 
four  drams  of  port  wine. 

When  the  inclination  for  a  movement  begins  to  be  felt,  an  injection 
of  warm  sweet-oil  into  the  rectum  will  facilitate  it,  and  prevent  any 
friction  by  the  fecal  mass  upon  the  stumps  and  ligatures.  In  the  major- 
ity of  cases  the  patient  may  sit  upon  the  commode  for  this  purpose; 
it  makes  the  movement  easier  and  causes  less  straining  than  when 
the  bed-pan  is  used.  As  Allingham  says,  there  are  patients  so  anemic 
and  debilitated  that  the  recumbent  posture  is  desirable,  and  in  these 
the  use  of  the  bed-pan  for  several  days  will  be  necessary.  After  the 
bowels  have  once  moved,  boric-acid  solution  should  be  injected  into 
the  rectum,  and  expelled  again  in  order  to  wash  away  any  fecal  ma- 
terial which  may  have  adhered  to  the  raw  surfaces.  If  there  is  any 
difficulty  in  obtaining  a  movement  of  the  bowels,  the  finger  should  be 
introduced  at  once  to  ascertain  if  impaction  has  taken  place;  and  if 
so,  it  should  be  broken  up.  Allingham  advises  the  introduction  of  the 
finger  into  the  bowel  every  day  after  the  first  week  in  order  to  avoid  any 
contraction;  he  confines  the  patient  to  bed  for  one  week  or  more,  and 
does  not  allow  him  to  walk  about  until  the  wounds  are  healed. 

After  the  bowels  have  moved  for  the  first  time,  gentle  traction  should 
be  made  upon  the  ligatures  daily  in  order  to  withdraw  them  when  they 
have  cut  their  way  through.  This  should  be  very  carefully  done  lest 
too  much  dragging  should  tear  off  a  pedicle  and  thus  bring  about 
secondary  hemorrhage. 

The  time  required  for  complete  healing  by  the  ligature  method  is 
from  twenty-five  to  forty  days.  The  period  of  confinement  to  bed  is 
from  five  days  to  three  weeks. 

After-treatment  of  the  Clamp  and  Cautery  Method. — There 
are  two  methods  of  treating  the  wounds  following  removal  of  the  hemor- 


OPERATIONS   UPON   THE   RECTUM,   ETC.  251 

rhoids.  One  is  the  application  of  a  soft,  fluffy  piece  of  gauze  infillrated 
with  iodoform,  xeroform,  or  orthoform  to  the  external  raw  surfaces. 
This  is  covered  with  a  good  pad  of  gauze  or  absorbent  cotton,  and  held 
in  position  by  a  T-bandage.  If  the  sphincter  is  thoroughly  relaxed, 
and  if  there  is  no  tendency  to  contract,  this  dressing  is  quite  as  satis- 
factory as  any  other.  In  many  cases,  however,  it  seems  impossible 
to  paralyze  the  sphincter  muscles  by  stretching,  and  in  such  cases  it 
is  customary  to  use  a  Pennington  tube,  which  consists  of  a  piece  of  me- 
dium-sized stiff  rubber  tubing  about  six  inches  long,  attached  to  which 
is  a  sheath  of  very  thin  rubber.  The  tube  or  part  to  be  inserted  is 
wrapped  with  iodoform  gauze  until  its  size  is  sufficient  to  keep  the 
sphincter  well  dilated,  and  the  rubber  sheathing  is  then  folded  over 
the  gauze.  The  part  of  the  tube  surrounded  by  the  gauze  is  then  in- 
troduced about  four  inches  into  the  rectum  wdth  the  uncovered  end  of 
the  tube  protruding  from  the  anus,  orthoform  or  iodoform  having  been 
previously  dusted  freely  upon  the  raw  surfaces  within  and  about  the 
anus.  The  tube  serves  to  allow  the  escape  of  any  gas  which  may  ac- 
cumulate within  the  rectum,  to  control  hemorrhage,  and  to  maintain 
the  dilatation  of  the  sphincter.  The  rubber  sheath  prevents  granulations 
from  forming  in  the  meshes  of  the  gauze.  The  gauze  is  then  packed 
around  the  lower  end  of  the  tube  and  a  snug  T-bandage  applied,  through 
which  the  end  of  the  tube  protrudes  in  order  to  prevent  pressure  upon 
the  latter.  A  large  safety-pin  is  fastened  through  the  end  of  the  tube 
in  order  to  prevent  its  escape  upward  into  the  rectum,  and  thus  the 
dressing  is  completed. 

As  a  rule,  it  is  best  not  to  use  any  plug  or  tampon  in  the  rectum, 
but  when  there  is  much  pain  and  contraction  of  the  sphincter,  the 
method  of  Pennington  will  prove  of  great  service.  The  tube  should 
be  allowed  to  remain  until  the  third  or  fourth  day,  or  be  allowed  to  come 
away  with  the  first  movement  of  the  bowels.  When  the  tube  is  used, 
the  patients  generally  have  to  be  catheterized,  and  it  may  be  necessary 
to  administer  one  or  two  hypodermatics  of  morphin  during  the  first 
twenty-four  hours.  It  is  customary  to  give  a  hypodermatic  injection 
of  morphin,  J  to  ^  grain,  before  the  patient  leaves  the  operating  table. 
On  the  second  night  following  the  operation  20  to  30  minims  of  fluid 
extract  of  cascara  or  castor  oil  may  be  administered,  and,  as  before 
directed,  when  the  bowels  feel  like  moving,  warm  sweet-oil  should  be 
injected  into  the  rectum.  After  the  bowels  have  moved  and  the  rec- 
tum has  been  irrigated,  a  small  piece  of  gauze  infiltrated  ^^•ith  some 


252  POSTOPERATIVE    TREATMENT. 

antiseptic  powder  should  be  applied  to  the  anus  two  or  three  times  a 
day,  to  keep  it  dry.  If  there  is  a  tendency  to  contraction  or  spasm 
of  the  sphincter,  a  full-sized  rectal  bougie  should  be  introduced  daily. 

The  time  for  healing  after  this  operation  varies  from  two  to  four 
weeks,  the  average  being  twenty-one  days.  Patients  are  allowed  to 
get  out  of  bed  after  the  bowels  have  moved  on  the  third  or  fourth  day. 
They  can  generally  walk  about  without  any  distress,  but  sitting  may 
be  uncomfortable.  They  are  allowed  to  use  a  commode  for  the  first 
movement  of  the  bowels.  There  is  often  some  hemorrhage  after  stools 
for  the  first  week  or  ten  days,  but  it  is  never  alarming,  and  only  comes 
from   granulating   surfaces. 

Crushing  Method. — Some  recent  operators  have  used  the  angio- 
tribe  in  carrying  out  the  crushing  operation.  Other  instruments  have 
been  invented  and  used  for  this  purpose,  viz..  Smith's  and  Allingham's 
being  the  most  frequently  used,  but  none  are  superior  to  the  old  Kelsey 
clamp.  After  having  crushed  the  hemorrhoids,  collodion  should  be 
applied.  The  parts  will  often  heal  as  if  they  had  been  sutured.  The 
cauterization  of  the  stump  before  applying  the  collodion  is  a  safeguard 
against  hemorrhage. 

Following  the  excision  method,  pain  is  usually  very  great  for  eight 
to  ten  hours.  Morphin  is  the  best  remedy  to  control  it  after  all  opera- 
tions, but  if  the  patient  is  extremely  nervous,  large  doses  of  sodium 
bromid  will  act  more  satisfactorily.  The  smarting  pain  which  follows 
the  movement  of  the  bowels  in  either  operation  may  be  relieved  by 
the  application  of  pure  iodoform  or  a  lo  percent  ichthyol  ointment, 
or  the  insufflation  of  orthoform  just  before  the  stool. 

Strangury  and  dysuria  very  frequently  occur  after  the  ligature 
method.  Hot  applications  over  the  pubis  and  allowing  the  patients 
to  stand  on  their  feet  will  frequently  enable  them  to  pass  their  urine 
voluntarily;  but,  these  methods  failing,  catheterization  should  be 
performed  under  strict  asepsis. 

Secondary  Hemorrhage. — The  danger  of  secondary  hemorrhage 
is  very  much  exaggerated.  If  severe,  the  rectum  may  be  thoroughly 
packed  with  gauze.  The  introduction  of  astringents  is  unnecessary 
and  injurious. 

Abscess  and  Fistula. — These  conditions  have  been  known  to  fol- 
low operations  by  ligature,  by  the  clamp  and  cautery,  and  by  the  ex- 
cision methods,  and  are  usually  the  result  of  faulty  drainage.  The 
only  treatment  in  these  cases  is  to  dilate  the  sphincter  thoroughly  and 


OPERATIONS    UPON    THE    RECTUM,    ETC.  283 

drain  the  abscess  as  soon  as  the  swcllinj^  is  discovererl.  After  excision, 
the  abscess  may  form  in  the  stitch  holes.  As  soon  as  they  ajjpear  the 
surgeon  should  remove  the  stitches  and  thus  give  exit  to  the  pus.  A 
sudden  rigor  with  rise  of  temperature  after  forty-eight  hfjurs  or  more 
following  the  operation  should  excite  suspicion  and  cause  immediate 
examination  of  the  parts. 

Stricture. — Stricture  rarely  follows  except  after  the  Whitehead 
operation,  and  is  usually  due  to  cicatricial  contraction.  The  rectum 
should  be  dilated  daily  with  a  moderate-sized  bougie  until  the  wound 
is  entirely  healed. 

Ulceration  and  Fissure. — Protracted  ulceration  or  chronic  fissure 
sometimes  follows  the  Whitehead  and  ligature  operations.  The  con- 
stitutional condition  of  the  patient  accounts  for  the  majority  of  cases. 
Dilatation  of  the  sphincter  under  anesthesia  wdth  applications  of  iodo- 
form or  ichthyol  ointment  usually  affords  prompt  relief. 


EXTIRPATION  OF  THE  RECTUM. 

Preparation  of  the  Patient.— In  order  to  obtain  the  best  result 
it  is  necessary  to  increase  the  patient's  strength  as  much  as  possible  by 
forced  feeding  for  a  time.  The  intestinal  tract  must  be  emptied  of  all 
hard  and  putrefying  fecal  masses,  to  establish  so  far  as  possible  intes- 
tinal asepsis.  Seven  to  ten  days  are  usually  required  to  properly 
prepare  a  patient  for  this  operation. 

An  absolute  milk  diet  is  not  so  satisfactory  as  a  mixed  diet  com- 
posed of  meat  broth,  milk,  and  small  quantities  of  bread  and  refined 
cereals.  The  patient  should  be  fed  at  frequent  intervals,  and  given 
as  much  as  he  can  digest.  Daily  saline  laxatives  should  be  given  in 
sufficient  quantity  to  produce  two  or  three  thin  movements.  The  rec- 
tum should  be  irrigated  by  mild  antiseptic  solutions  of  mercuric 
chlorid,  potassium  permanganate,  or,  as  recommended  by  Quenu, 
hydrogen   dioxid. 

Numerous  methods  have  been  devised  by  various  surgeons  for  ex- 
tirpation of  the  rectum  by  the  perineal  route,  but  on  account  of  the  vast 
areas  of  tissue  laid  open,  and  the  unsatisfactory  access  to  the  rectum 
which  they  give,  they  have  practically  been  rejected,  though  Cripps' 
and  Allingham's  methods  remain  popular,  owdng  to  the  fact  that  the 
mortality  from  extirpation  of  the  rectum  by  the  perineal  route  is  much 
lower  than  by  any  other  method.     After  removal  of  the  rectum  by 


284  POSTOPERATIVE    TREATMENT. 

either  of  these  methods  the  posterior  and  anterior  portions  of  the  peri- 
neal wound  are  packed  with  iodoform  gauze  and  left  open  to  insure 
drainage.  The  parts  are  covered  with  aseptic  pads  held  in  position 
by  well-fitting  diaper  or  broad  T-bandages.  A  large  drainage-tube 
is  passed  well  up  into  the  rectum,  its  lower  end  extending  outside  of 
all  the  dressings  in  order  to  convey  the  discharge  and  gases  beyond 
the  operative  wound. 

Kraske's  Operation,  or  the  Sacral  Method. — ^After  all  oozing 
is  checked  by  hot  compresses,  the  cavity  of  the  sacrum  is  packed  with 
a  large  mass  of  iodoform  or  sterilized  gauze,  the  end  of  which  protrudes 
from  the  lower  angle  of  the  wound.  The  skin-flap  is  sutured  in  its 
original  position  with  silkworm-gut  which  passes  deeply  through  the  skin. 
The  lateral  portion  of  the  wound  is  closed  by  similar  sutures  down  to 
the  level  of  the  sacrococcygeal  articulation.  Below  this  it  is  left  open 
for  a  drainage.  A  large  rubber  drainage-tube  is  carried  up  through 
the  gut  beyond  the  line  of  intestinal  sutures,  and  the  whole  is  dressed 
with  iodoform  or  sterilized  gauze,  held  in  position  by  adhesive  straps 
and  a  firm  T-bandage.  The  patient  is  placed  in  bed,  lying  upon  his 
back  or  right  side,  and  the  head  of  the  bed  is  elevated  slightly  in  ordei 
to  afford  better  drainage.  There  is  always  considerable  oozing  for 
the  first  twenty-four  hours  following  the  operation,  during  which  time 
the  outside  dressings  should  be  replaced  several  times  by  fresh  ones. 
The  inner  packing  or  drainage  should  be  left  in  position  for  seventy- 
two  hours;  after  this  it  is  removed,  and  either  drainage-tubes  or  small 
gauze  strips  are  introduced  into  the  hollow  of  the  sacrum.  The  patient 
is  kept  upon  concentrated  liquid  diet,  and  if  a  preliminary  artificial 
anus  has  not  been  employed,  his  bowels  should  be  confined  by  opium 
for  the  first  ten  days,  after  which  they  are  moved  by  enemas  of  oil  and 
glycerin. 

The  Vaginal  Method. — Extirpation  of  cancer  of  the  rectum 
through  the  vagina  or  the  removal  of  carcinoma  of  the  lower  loop  of 
the  sigmoid  via  the  vagina  has  been  popularized  by  Murphy,  of  Chicago. 
After  extirpation,  the  peritoneum  is  closed  with  a  continuous  catgut 
suture  and  the  vaginal  wound  is  brought  together  with  silkworm-gut 
sutures.  A  large  drainage-tube  is  introduced  through  the  anus  above 
the  point  of  anastomosis  and  sutured  in  position.  The  vagina  and 
external  parts  are  dressed  with  iodoform  gauze.  In  order  to  facilitate 
better  drainage,  Tuttle  recommends  a  semicircular  incision  between 
the  anus  and  the  coccyx,  extending  into  the  retrorectal  space,  and 


OPERATIONS    UPON    TMK   KECTUM,    ETC.  285 

through  this  incision  the  sacral  concavity  is  packed  witli  iofloform  gauze. 
The  use  of  silkworm-gut  sutures  in  the  intestinal  wall  necessitates 
their  removal  under  anesthesia  on  the  twelfth  or  fourteenth  day.  The 
use  of  a  ten-day  chromicized  catgut  serves  every  purpose  and  does  not 
require  removal. 

Combined  Methods. — The  combination  of  abdominal  with  other 
methods  for  extirpation  of  the  rectum  has  been  suggested  from  time  to 
time.  Abdomino-anal,  abdomino-peritoneal,  abdomino-sacral,  all  have 
their  advocates.  Mayo's  modification  of  Maunsell's  method  is  a  fine 
conception,  and  may  prove  later  the  ideal  method.  The  after-treat- 
ment in  all  forms  being  practically  the  same,  recovery  is  dependent 
upon  proper  drainage. 

When  end-to-end  approximation  of  the  bowel  has  been  employed, 
a  large,  firm,  rubber  drainage-tube  should  be  passed  through  the  anus 
and  extend  above  the  line  of  anastomosis  in  order  to  prevent  any 
tension  upon  these  parts  from  the  accumulation  of  gases  or  fecal 
material. 

Postoperative  Complications. — Sepsis. — The  chief  complica- 
tion which  follows  all  forms  of  operation  of  extirpation  is  sepsis. 
According  to  Tuttle,  75  percent  of  the  deaths  occurring  from  extirj^a- 
tion  for  cancer  of  the  rectum  are  caused  by  infection.  Whether  this 
is  due  to  faulty  technic,  to  the  escape  of  fecal  material  during  the  opera- 
tion, to  ruptures  of  the  sutures  after  the  operation,  or  to  the  presence 
of  bacilli  in  the  perirectal  tissues  at  the  time  of  the  operation,  it  is  im- 
possible to  say.  No  technic  has  been  devised  which  will  positively  se- 
cure asepsis  in  all  operations  of  this  type.  A  certain  amount  of  sepsis, 
therefore,  is  unavoidable.  Every  effort  should  be  made  to  protect  the 
peritoneum. 

Gangrene. — Gangrene  is  the  next  most  serious  postoperative  com- 
plication. This  may  be  the  result  of  deficient  blood-supply,  too  great 
tension  of  stitches,  etc.,  or  may  result  from  infection.  If  from  either 
of  the  first  two  causes,  the  condition  will  develop  within  the  first  twentv- 
four  to  thirty-six  hours.  If  from  the  latter,  the  intestine  may  appear 
perfectly  healthy  for  two  or  three  days,  and  then  entirely  slough  away. 
There  is  no  possible  way  to  avoid  these  complications  except  through 
the  most  rigid  asepsis.  The  systematic  employment  of  a  preliminary 
colostomy  simplifies  the  after-treatment  and  lessens  mortahty. 

Incontinence  of  feces  is  a  very  frequent  complication  follow- 
ing the  sacral  method  of  extirpation.     To  avoid  this,  Gersuny  has  pro- 


200  POSTOPERATIVE    TREATMENT. 

posed  twisting  the  gut  two  or  three  times  around  before  it  is  sutured 
in  position.  Willems  carries  the  superior  segment  of  the  intestine 
through  the  fibers  of  the  gluteus  maximus  muscles,  thus  constituting 
a  sphincter  ani.- 

FISTULA  IN  ANO. 

Technic. — There  are  several  methods  of  operating  for  fistula,  and 
the  after-treatment  varies  accordingly.  The  operation  by  radical  ex- 
cision as  first  recommended  by  Stephen  Smith,  of  Bellevue  Hospital, 
is  now  generally  adopted.  A  medium-sized  rectal  tube  wrapped  with 
a  small  quantity  of  gauze  and  covered  with  rubber  protective  is  intro- 
duced about  three  inches  into  the  rectum  and  allowed  to  remain  for 
several  days,  in  order  to  facilitate  the  escape  of  gas  which  may  come 
from  the  intestine  above. 

The  after-treatment  of  this  method  is  as  follows:  The  patient 
is  confined  absolutely  to  bed,  the  bowels  are  controlled  by  opiates  for 
six  or  seven  days,  the  patient  being  limited  to  albuminoid  diet,  but  milk 
is  excluded.  At  the  end  of  six  or  seven  days  the  bowels  are  moved 
by  the  injection  of  five  ounces  of  warm  water  and  one  ounce  of  glycerin, 
in  which  is  dissolved  two  ounces  of  inspissated  oxgall.  This  proceeding 
may  have  to  be  repeated  several  times  before  an  efficient  evacuation 
is  obtained,  but  Smith  does  not  consider  it  advisable  to  attempt  the  use 
of  any  laxative  or  purgative  until  the  lower  bowels  have  been  relieved 
of  any  accumulation  of  hardened  fecal  masses,  such  as  are  likely  to 
follow  the  administration  of  opium  and  prolonged  constipation.  After 
these  masses  have  been  dissolved  by  the  above  method  one  may  then 
administer  some  mild  laxative  and  induce  daily  movements. 

Rest  in  bed  is  incumbent  upon  these  patients  for  at  least  two 
weeks  in  order  to  secure  firm-  and  perfect  healing  of  the  part.  The 
stitches  are  usually  removed  about  the  seventh  day,  but  not  before 
movement  has  been  secured. 

When  primary  union  fails,  resort  must  be  had  to  healing  by 
granulation,  the  wound  being  treated  similarly  to  other  septic  wounds. 
The  large  majority  of  failures  which  follow  operations  for  fistula  are 
due  to  one  of  two  facts,  either  a  specific  fistula  is  mistaken  for  a  simple 
one,  or  the  opening  into  the  rectum  is  not  found  and  thus  a  part  of 
the  track  remains.  The  method  of  after-treatment  advocated .  by 
Grant,  Tuttle,  and  others  varies  somewhat  from  the  above,  hence  is 
given  in  full. 


OPKKATIONS    UPON    TKK    KKCTUM,    KTC.  287 

Postoperative  Treatment  for  Fistula  in  Ano  (Method  of  Grant;. 

— It  may  almost  be  said  that  Ihc  iiftcT-lrealment  of  the  case  is  of  more 
importance  than  the  operation.  When  all  bleeding  has  been  checked, 
the  parts  should  be  well  dried,  and  a  folded  piece  of  lint,  or,  better 
still,  a  stri])  of  iodoform  gauze,  should  then  be  lightly  j;acked  into  the 
incision.  A  large  pad  of  wool  is  applied  over  the  part  to  maintain 
pressure,  and  to  overcome  any  inclination  to  strain,  and  is  fixed  in  place 
by  a  T-bandage.  This  outer  dressing  can  be  replaced  later  by  a  sani- 
tary towel  only.  A  suppository  containing  morphin  may  be  employed. 
In  forty-eight  hours  the  first  dressing  should  be  removed,  the  part  well 
washed,  and  redressed.  The  dressing  consists  of  a  folded  piece  of 
lint  or  of  gauze  firmly  packed  in  the  wound.  It  may  be  moistened  with 
oil,  or  with  iodoform  or  other  ointment,  or  may  be  merely  dusted  with 
iodoform.  The  whole  of  the  gap  or  gaps  made  by  the  operation  must 
be  well  and  carefully  stuffed  from  the  bottom. 

The  part  should  be  dressed  night  and  morning  and  after  each  action 
of  the  bowels.  Scrupulous  cleanliness  must  be  insisted  upon.  A  hip- 
bath may  be  taken  daily  after  the  action  of  the  bowels.  The  bowels 
should  at  first  be  kept  confined,  but  should  be  opened  by  means  of  a 
dose  of  castor  oil  on  the  third  or  fourth  day.  It  must  be  seen  that 
they  act  regularly  after  this.  The  discharge  will  be  free  for  about 
the  first  ten  days.  The  dressing  may  need  to  be  changed  from  time 
to  time,  and  the  lint  may  be  soaked  Avith  zinc  sulfate  lotion,  with  a 
silver  nitrate  solution,  with  the  compound  tincture  of  benzoin,  with  weak 
iodin,  or  with  such  other  drug  as  the  surgeon  employs  in  like  cases. 

The  parts  may  be  overdressed  and  the  skin  around  be  kept  in  a 
condition  of  irritable  inflammation.  Every  care  must  be  taken  that 
the  skin  does  not  heal  over  prematurely,  and  a  constant  watch  must 
be  kept  for  burrowing  sinuses  and  for  undermining  of  the  skin. 
Pockets  for  pus  soon  form,  and  good  drainage  should  be  maintained 
throughout. 

The  diet  should  be  simple,  but  not  meager.  Every  means  should 
be  taken  to  improve  the  general  health. 

The  operation  will  probably  require,  in  an  ordinary  case,  confine- 
ment in  bed  for  some  fourteen  days,  followed  by  another  week  or  so 
in  the  house.  In  a  complex  case,  with  many  deep  sinuses,  the  after- 
treatment  may  extend  over  many  months.  Rest  is  all-important,  and 
the  healing  process  is  very  distinctly  retarded  by  too  early  movement. 
Change  of  air  will  often  do  more  for  an  indolent  sinus  than  will  the 


288  .   POSTOPERATIVE    TREATMENT. 

most  elaborate  dressing.  Some  loss  of  power  over  the  sphincter  will 
be  noticed  for  a  little  while.  It  is  generally  regained  within  three 
weeks.  A  permanent  weakening  of  the  anus  may  result,  but  it  is  very 
uncommon. 

The  treatment  of  fistula  by  the  elastic  ligature  was  at  one  time 
extensively  employed.  It  is  attended  by  no  hemorrhage,  and  was  recom- 
mended for  cases  of  deeply  extending  fistula.  The  ligature  is  made 
of  a  solid  cylindric  rubber  cord,  one-tenth  of  an  inch  in  diameter.  One 
end  of  the  loop  is  introduced  along  the  sinus  by  means  of  a  special 
director,  while  the  other  end  hangs  in  the  rectum.  A  pewter  ring  is 
then  threaded  over  the  two  ends,  and  as  the  ligature  is  drawn  tight, 
the  ring  is  made  to  clamp  the  two  cords  by  compressing  it  with  necrosis 
forceps.  The  ligature  is  allowed  to  cut  its  own  way  out.  This  it  will 
effect,  on  an  average,  in  six  days.  There  is  little  to  recommend  the 
measure,  which  is  attended  by  no  little  pain.  In  individuals  suffer- 
ing from  hemophilia,  I  imagine  the  risks  of  bleeding  would  be  as  great 
after  the  use  of  the  ligature  as  of  the  knife.  It  has  not  been  shown 
that  the  after-treatment  is  shortened  by  this  method. 

URETHROTOMY. 

General  Remarks. — After  operations  upon  the  urethra  the  former 
custom  of  allowing  the  catheter  to  remain  has  been  abolished  largely, 
for  the  reason  that  it  is  not  only  uncomfortable  to  the  patient,  but  fre- 
quently produces  urethritis;  nor  is  it  essential  that  a  drainage-tube 
should  be  introduced  into  the  perineal  opening.  The  best  plan  is  to 
allow  the  wound  to  remain  open  and  have  the  urethra  irrigated  several 
times  a  day  with  warm  Thiersch's  solution  and  have  the  perineal  wound 
kept  thoroughly  clean  by  the  same  means.  By  the  use  of  proper  anti- 
septics the  urine  is  soon  made  aseptic,  which  tends  to  keep  the  part 
free  from  infection.  A  full-sized  sound  should  be  passed  every  three 
or  four  days  until  the  urethra  is  healed.  A  pad  is  usually  placed  be- 
tween the  knees  and  the  limbs  kept  together  by  means  of  broad  bandages 
to  prevent  the  careless  spreading  of  the  thighs.  Should  an  abscess 
or  swelling  form  in  the  region  of  the  perineum,  which  is  usually  accom- 
panied with  severe  pain  and  symptoms  of  acute  suppuration,  it  must 
be  evacuated  through  the  perineal  incision,  being  careful  not  to  injure 
either  the  rectum  or  the  urethra,  and  after  thorough  evacuation  the 
cavity  should  be  tamponed  with  iodoform  gauze.  The  opening  in  all 
cases  should  be  made  large  enough  to  insure  permanent  drainage. 


OPERATIONS    UPON    I' III':    HV.CTUM,    ETC. 


289 


Some  surgeons  prefer  to  open  prostatic  abscesses  into  the  rectum 
to  avoid  infection.  If,  however,  the  perineal  incision  just  describcfl 
has  been  made,  and  if  the  patient  has  received  projjer  prehminary  treat- 
ment, consisting  of  a  thorough  laxative  and  flushing  of  the  bowels 
previous  to  performing  the  operation,  the  perineal  method  is  preferable. 
The  administration  of  saline  laxatives  daily  and  thorough  flushing 
after  the  evacuation  of  the  bowels  tend  to  render  the  patient  more 
comfortable  and  the  results  more  satisfactory.  The  patient  should 
be  placed  in  bed  on  his  back,  with  some  absorbent  material  under 
his  buttocks  to  catch  the  urine;    his  thighs  should  also  be  protected 


Fig.  75. — Section  of  Hypertrophied  Prostate. — {Duplay  and  Rectus.) 

U,  Urethra;  E,  ejaculatory  ducts;  T,  j&brous  tuberculse;  C,  prostatic  nodules; 
Z,  fibroniuscular  capsule;  V,  periprostatic  veins;  F,  fibroglandular  tissue;  S,  section 
of  seminal  vesicles. 


from  the  irritation  caused  by  the  urine  by  means  of  benzoated  zinc 
oxid  ointment  and  by  frequent  sponging  with  alcohol  or  boric  acid. 

Immediate  suture  of  the  perineal  wound  has  been  tried,  but  ex- 
perience shows  that  it  is  attended  with  great  risk;  the  deep  portions 
of  the  wound,  which  have  been  more  or  less  bruised  by  instruments, 
may  slough  slightly  or  heal  more  slowly  than  the  skin- surfaces,  and 
in  this  event  extravasation  of  urine  is  likely  to  occur;  whereas  if  the 
wound  be  allowed  to  close  slowly,  healing  begins  at  the  bottom.  After 
perineal  lithotomy  the  patient  should  remain  in  bed  for  from  two  to 
four  weeks,  except  in  cases  of  children,  who  recover  very  rapidly  after 
the  operation. 


290  POSTOPERATIVE    TREATMENT. 

Internal  Urethrotomy. — Should  hemorrhage  occur  after  internal 
urethrotomy,  an  ice-bag  should  be  applied  to  the  perineum  with  ele- 
vation of  the  pelvis,  or  a  full-sized  catheter  (flexible,  if  possible)  may  be 
passed  and  left  in,"  while  a  firm  pad  of  wool  is  fixed  against  the  perineum 
by  a  T-bandage.  The  catheter  should  be  kept  clear,  and  the  urine 
should  run  continuously  through  it  and  an  attached  rubber  tube.  An 
opiate  should  be  given  if  there  is  pain  or  restlessness. 

In  order  to  keep  the  cut  surfaces  from  growing  together,  a  sound 
should  be  passed  every  day  for  the  first  week,  and  subsequently  every 
second  or  third  day.  Later,  the  passage  of  the  sound  need  take  place 
only  once  a  month,  but  there  is  always  danger  of  contraction  unless  a 
sound  is  passed  at  intervals. 

To  avoid  rigors  after  internal  urethrotomy,  the  patient  should  be 
kept  thoroughly  warm  in  bed,  should  not  try  to  pass  urine  for  a  fcAV 
hours,  and  should  drink  freely  warm  water  or  weak  tea.  Should  a 
rigor  occur,  it  should  be  met  by  the  immediate  administration  of  10 
grains  of  quinin  in  hot  brandy  and  water. 

External  Urethrotomy. — When  clamp  forceps  have  been  used 
and  left  in  situ  to  control  hemorrhage,  they  may  be  removed  safely 
in  thirty-six  hours.  General  oozing  is  then  controlled  by  firm  pressure 
with  iodoform  gauze  packed  into  the  wound  and  around  the  drainage- 
tube  or  catheter. 

The  most  important  indication  after  urethrotomy  is  not  only  thorough 
drainage  from  the  bladder,  but  every  effort  should  be  made  to  prevent 
the  urine  from  coming  in  contact  with  the  freshly  made  wound  until 
septic  absorption  is  guarded  against  by  the  formation  of  granulations. 
This  is  ordinarily  accomplished  by  carrying  a  large  rubber  drainage- 
tube  or  No.  30  French  catheter  through  the  wound  into  the  bladder 
and  stitched  to  the  wound  to  prevent  its  being  forced  out.  Iodoform 
gauze  is  then  carefully  packed  around  the  catheter.  The  end  of  the 
drainage-tube  or  catheter  is  then  attached  to  a  large  tube  which  drains 
into  a  urinal,  or  if  desired,  a  vessel  on  the  floor. 

The  gauze  packing  should  be  removed  from  around  the  tube  in 
forty-eight  hours  and  the  wound  irrigated  with  hydrogen  dioxid  and 
carefully  repacked.  The  bladder  should  also  be  irrigated  thoroughly 
at  least  once  a  day  with  Thiersch's  fluid.  About  the  seventh  to  the 
tenth  day  after  the  operation,  when  granulations  are  formed,  the  drain- 
age-tube should  be  removed  from  the  wound  and  a  curved  sound 
passed  into  the  bladder.     The  sound  is  passed  every  second  or  third 


OPERATIONS    UPON    TIIK    KKCTUM,    KTC.  2(jl 

day  into  the  bladder  unlil  tlic  ])crineal  wound  is  hc-alcrl,  when  the 
patient  may  l^e  discharged.  Should  a  stricture  also  exist  in  the  an- 
terior part  of  the  urethra,  it  may  be  divided  by  internal  urethrotomy, 
after  which  a  large  straight  sound  should  be  passed  through  the  meatus 
and  anterior  urethra  down  to  the  drainage-tube  or  posterior  perineal 
opening.  This  should  be  repeated  every  alternate  day  until  the  drain- 
age-tube has  been  removed  from  the  wound  and  bladder. 

From  the  first  the  patient  is  placed  upon  a  light  diet  and  directed 
to  drink  freely  of  water  and  milk  to  dilute  the  urine.  Five-grain  doses 
of  urotropin  thrice  daily  may  also  be  given  as  an  antiseptic.  After 
the  first  forty-eight  hours  the  patient  may  be  allowed  to  assume  a  sit- 
ting position  in  bed,  and  a  week  after  the  operation  may  be  permitted 
to  sit  in  a  chair.  On  closure  of  the  perineal  opening  the  patient  usually 
has  the  ability  to  retain  the  urine  in  a  normal  manner.  Stricture  is 
almost  certain  to  take  place  unless  the  patient  passes  a  sound  at  inter- 
vals. He  should,  therefore,  be  taught  how  to  do  this  without  injury, 
and  the  fact  of  its  neglect  must  be  earnestly  impressed  upon  him  so 
that  he  may  not  neglect  the  precaution. 

Postoperative  Infiltration  or  Extravasation  of  Urine. — Post- 
operative infiltration  or  extravasation  of  urine  may  occur  as  a  result  of 
too  rapid  healing  and  failure  to  keep  the  urethra  well  dilated.  Ob- 
struction of  the  drainage-tube  by  means  of  blood-clot  or  faulty  dress- 
ings, and  attempts  of  the  patient  himself  to  void  urine  by  straining 
and  pressure,  may  cause  a  rupture  of  the  thin  walls  of  the  urethra, 
and  the  urine  may  thus  escape  into  the  cellular  tissues.  It  occasion- 
ally happens  after  operations  for  stricture;  premature  closing  of  the 
wound  or  attempts  at  the  introduction  of  a  catheter  or  sound  mav 
result  in  a  false  opening  in  the  posterior  urethra,  and  extravasation 
follow. 

When,  as  is  frequently  the  case,  the  extravasation  occurs  in  front 
of  the  subpubic  ligament,  the  urine  burrows  through  the  cellular  tis- 
sue of  the  scrotum  and  penis,  and  extends  upward  toward  the  h}^o- 
gastrium.  Abscess  rapidly  forms,  the  tissues  become  gangrenous  and 
slough,  and  spontaneous  evacuation  of  the  pus  and  urine  occurs,  with 
considerable  destruction  of  tissue,  leaving  urinary  fistulas.  The  sep- 
tic condition  is  always  very  pronounced,  and  such  patients  usually 
die  unless  an  operation  is  performed  promptly. 

When  the  rupture  of  the  urethra  takes  place  posterior  to  the  sub- 
pubic ligament,  the  burrowing  of  urine  takes  place  in  a  different  di- 


292  POSTOPERATIVE    TREATMENT. 

rection.  In  this  case  the  urine  cannot  make  its  way  forward  through 
the  cellular  tissue  of  the  penis,  but  it  burrows  under  the  deep  layer  of 
the  perineal  fascia  and  accumulates  in  the  prevesical  space,  forming 
a  swelling  above  the  symphysis.  From  this  point  it  extends,  and 
inflammatory  swelling  and  suppuration  of  the  connective  tissue  within 
the  abdomen  occur  and  the  patient  dies  of  pyemia. 

Treatment. — Urinary  extravasation  demands  immediate  opera- 
tion in  order  to  save  the  patient's  life  and  prevent  extensive  sloughing 
and  loss  of  tissue.  An  external  incision  should  be  made  and  the  bladder 
drained  through  a  catheter  in  order  to  prevent  further  escape  of  urine 
into  the  tissues.  The  collections  of  pus  and  urine  in  the  tissues,  no 
matter  where  located,  should  be  opened  up,  drained  freely,  and  packed 
with  gauze.  If  the  prostatic  urethra  was  ruptured  behind  the  subpubic 
ligament  and  extravasation  has  taken  place  into  the  prevesical  space, 
the  pus  and  urine  should  be  evacuated  by  means  of  a  suprapubic 
cystotomy.  • 

AFTER-TREATMENT  IN   REMOVAL  OF  THE   PROSTATE  AND 
OF  THE  PROSTATIC  URETHRA. 

Moynihan's  Method. — Moynihan  gives  the  following  directions: 
"The  catheter  is  passed  after  the  removal  of  the  organ,  and  the  bladder 
freely  flushed  with  hot,  sterile  saline  solution  or  a  hot  i  percent  solu- 
tion of  carbolic  acid.  When  the  fluid  returns  almost  clear,  a  large 
rubber  tube  is  passed  into  the  bladder,  and  a  couple  of  stitches  intro- 
duced into  the  wound.  There  are  often  severe  paroxysms  of  pain 
for  a  few  hours  after  the  operation,  but  they  are  relieved  by  morphin. 
At  the  end  of  forty-eight  hours  the  tube  is  removed  from  the  bladder, 
and  the  patient  allowed  to  sit  up  with  a  bed-rest.  On  the  fourth  day 
and  each  succeeding  day  a  catheter  is  passed  and  the  bladder  freely 
washed  with  dilute  carbolic-acid  lotion.  On  the  seventh  day  the 
catheter  is  tied  in  and  a  drag  placed  on  the  suprapubic  wound,  which 
is  removed  every  morning  and  the  bladder  again  flushed.  The  catheter 
is  not  removed  for  five  or  six  days;  a  new  one  is  then  introduced.  The 
patient  is  allowed  to  get  up  and  sit  in  a  chair  at  the  end  of  the  first 
week  if  he  is  a  feeble  old  man.  The  urine  ceases  to  come  through 
the  wound  about  the  end  of  the  third  week,  and  at  the  end  of  the  fourth 
or  occasionally  not  until  the  end  of  the  fifth,  the  patient  is  passing 
urine  spontaneously  at  natural  intervals,  and  the  wound  is  entirely 


OPERATIONS  UPON  THE  RECTUM,  ETC.  29.3 

closed."  If  there  has  been  a  cystitis,  he  orders  urotnjpin  or  helmitol, 
10-  to  15-grain  doses  three  or  four  times  daily. 

Suprapubic  Prostatectomy. — No  attempt  is  made  to  sew  up  the 
bladder  wound,  the  two  stitches  inserted  into  each  edge  being  secured 
to  the  skin.  A  large  soft-rubber  tube  is  then  inserted  and  fixed  by  a 
stitch;  a  large  absorbent  dressing  is  now  applied  over  the  pubes,  and 
retained  by  a  many-tailed  bandage.  The  whole  of  the  urine  escapes 
through  the  wound  for  two  or  three  weeks,  and  very  frequent  change 
of  dressings  and  constant  attention  to  cleanliness  arc  required  on  the 
part  of  the  nurse. 

The  bladder  should  be  gently  washed  out  every  day  with  a  warm 
aseptic  solution.  The  tube  and  stitches  may  be  removed  in  two  or 
three  days'  time.  About  two  to  three  weeks  after  the  operation  the 
urine  begins  to  pass  through  the  urethra,  and  this  should  be  favored 
by  keeping  the  patient  in  the  sitting  posture  and  getting  him  out  of 
bed  as  soon  as  possible. 

If  the  entire  obstruction  has  been  removed,  the  bladder  will  re- 
gain control  in  from  a  month  to  six  weeks  after  the  operation.  The 
condition  of  "vesical  atony"  which  was  supposed  to  be  present  in 
many  cases  of  prostatic  enlargement  appears  to  have  no  real  existence. 
(Freyer.) 

Perineal  Prostatectomy. — The  open-wound  method  is  preferable 
when  the  perineal  operation  is  performed,  but  in  severely  infected 
bladder  cases  Ochsner  recommends  the  introduction  of  two  drainage- 
tubes  well  up  to  the  fundus  of  the  bladder,  so  that  irrigation  may  be  ac- 
complished by  injecting  fluid  through  one  tube  and  permitting  it  to 
escape  through  the  other  after  the  operation.  When  there  has  been 
considerable  hemorrhage  from  the  capsule  and  hemostatic  forceps 
have  been  applied  and  allowed  to  remain  and  protrude  through  the 
wound,  they  can  be  safely  removed  after  twelve  to  twenty-four  hours, 
or  if  there  has  been  considerable  oozing,  the  space  around  the  drainage- 
tubes  may  be  tamponed  with  a  sufficient  amount  of  iodoform  gauze, 
and  in  this  case  the  gauze  should  be  removed  on  the  third  or  fourth 
day.  In  all  cases  the  bladder  should  be  irrigated  with  normal  salt  or 
boric-acid  solution,  from  one  to  six  times  a  day,  according  to  the  con- 
dition of  the  bladder.  After  the  sixth  to  the  tenth  day  the  rubber  drain- 
age-tube should  be  removed.  At  this  time  the  patient  \\ill  ordinarily 
have  no  difficulty  in  evacuating  the  bladder  normally,  but  in  case  the 
flow  of  urine  is  not  normal,  a  soft-rubber  catheter  should  be  introduced 


294  POSTOPERATIVE    TREATMENT. 

through  the  urethra  into  the  bladder  for  a  few  days.  The  patient 
should  be  encouraged  to  sit  up  the  second  or  third  day  after  the  opera- 
tion, for  the  reason  that  elderly  men  do  not  bear  confinement  well. 

The  Scrotum. — For  the  removal  of  cancerous  or  tuberculous 
tumors  all  superfluous  scrotal  tissues  should  be  removed,  and  after 
removal  of  the  testes  all  bleeding  points  clamped  and  tied.  Oozing 
into  the  scrotum  gives  rise  to  much  trouble  on  account  of  the  laxity 
of  the  tissues,  and  the  long  time  it  requires  for  clot  to  become  absorbed, 
and  the  liability  to  infection.  As  scrotal  tissue  usually  swells  rapidly, 
care  should  be  taken  that  the  stitches  be  not  too  tightly  drawn.  Drain- 
age is  always  essential  in  scrotal  operations,  the  postoperative  treat- 
ment being  the  same  as  that  of  other  open  wounds,  drainage  being 
necessary  for  at  least  forty-eight  hours. 

In  patients  advanced  in  years  the  postoperative  shock  is  sometimes 
considerable,  hence  the  operation  should  be  performed  with  as  little 
traumatism  as  possible,  and  frequently  an  inguinal  incision  only 
should  be  made. 

Epididymitis  sometimes  occurs  as  a  complication  after  an  opera- 
tion upon  the  scrotum.  It  is  usually  manifested  by  severe  pain,  a 
chill,  followed  by  fever,  rapid  enlargement,  with  edema  of  the  scrotum. 

Treatment. — Rest  in  bed;  saline  purge;  wrap  testicles  in  lead- 
water  and  laudanum  and  elevate  with  handkerchief  bandage;  hot 
compresses  and  hot- water  bag  to  inguinal  region;  properly  fitted  sus- 
pensory bandage  strapped  in  recumbent  position  over  thick  sheet  of 
absorbent  cotton  or  wool;  in  severe  cases  puncture  vaginal  tunic  and 
cellular  tissue  at  back  of  scrotum  (introduce  knife  not  deeper  than 
one-half  inch)  and  then  apply  suspensory  bandage  or  elevate  testes 
with  handkerchief;  keep  testicle  constantly  wet  with  lead- water  and 
laudanum  on  lint  or  a  lo  percent  solution  of  iodoform  in  glycerin; 
morphin  hypodermatically  if  pain  is  severe;  later  incise  if  pus  is  sus- 
pected, and  drain  with  iodoform  gauze;  strapping  or  suspensory  ban- 
dage after  acute  symptoms  subside,  followed  later  by  application  of 
ointment  of  iodoform  i  part  to  7  parts  of  belladonna  ointment. 


CASTRATION. 

General  Considerations. — The  skin  incision  should  be  carried 
to  the  bottom  of  the  scrotum,  in  order  to  secure  good  drainage.  It 
may,  however,  be  noted  that  the  higher  up  the  incision  is  placed,  the 


Ol'iCRA'I'lONS    IJI'fJN    Till':    RICCTUM,    lOTC.  295 

more  easy  is  it  to  avoid  septic  contamination,  and  that  unless  the  testis 
is  of  great  si/e,  it  is  possible  to  remove  it  through  a  moderate  incision 
made  near  the  external  ring.  The  bottom  of  the  scrotum  may  then 
be  drained  for  twenty-four  hours  through  a  separate  jjuncture. 

When  the  skin  is  implicated  by  the  disease,  the  incisions  should 
extend  beyond  the  diseased  area  and  involve  sound  skin  only.  It  is 
not  necessary  to  remove  redundant  skin,  unless  it  be  excessive  in  amount 
and  much  atrophied.  If  any  sinuses  be  left  behind,  as  after  the  re- 
moval of  a  tuberculous  testis,  they  should  be  most  carefully  scraped 
with  a  Volkmann's  spoon.  The  cord  should  be  secured  about  one 
inch  from  the  testis.  If  it  be  involved,  it  should  be  divided  higher 
up.  It  can  seldom  be  necessary  to  open  up  the  whole  inguinal  canal 
to  secure  the  cord,  as  advised  by  some.  If  the  disease  has  extended 
to  the  external  ring,  the  expediency  of  any  operation  may  be  questioned. 
Before  the  cord  is  secured  and  divided  the  anesthetic  may  be  discon- 
tinued for  a  while,  as  the  section  is  sometimes  attended  by  a  very  marked 
and  sometimes  alarming  sinking  of  the  pulse. 

It  must  be  remembered  that  the  cord  is  very  much  dragged  down 
by  a  large  growth;  and  if  secured  very  high  up,  the  stump,  after  section, 
may  be  withdrawn  beyond  easy  reach  when  the  heaw  tumor  is  re- 
moved. 

The  chief  bleeding  to  be  feared  after  castration  is  venous  rather 
than  arterial.  It  is  unwise  to  include  the  entire  cord  in  one  ligature; 
the  vessels  are  not  well  secured  by  this  means.  The  loop  of  thread 
may  slip  off  when  the  clamp  is  removed.  A  substantial  ligature  (if 
single)  must  be  employed,  and  it  may  excite  suppuration  until  it  is  dis- 
charged. Secondary  hemorrhage  may  follow  the  loosening  of  the 
single  ligature.     Neuralgia  of  the  cord  may  also  attend  the  procedure. 

The  same  objections  apply,  but  in  a  less  degree,  to  the  practice  of 
transfixing  the  cord  with  a  needle  and  ligating  it  in  two  segments. 

Sometimes  a  tuberculous  or  syphilitic  testis  has  to  be  operated  on 
in  which  suppuration  has  already  supervened,  and  the  parts  are 
thoroughly  septic.  In  such  a  case,  although  all  possible  precautions 
are  taken  at  the  time  of  the  operation,  the  surgeon  can  hardly  hope 
for  primary  union,  and  free  provision  for  drainage  should  be  made. 
In  nearly  all  cases  of  tuberculous  orchitis  the  vas  is  invaded  wdth  tu- 
bercle bacilli  along  its  whole  course  by  the  time  the  patient  consents 
to  operation.  Owing  to  this  fact,  a  troublesome  complication  after 
simple  castration  is  the  development  of  a  secondary  lump  or  abscess 


296  POSTOPERATIVE    TREATMENT. 

around  the  severed  end  of  the  vas.  This  may  occur  weeks  or  months 
after  the  wound  has  apparently  healed.  Partly  to  avoid  this,  and 
also  to  make  a  complete  clearance  of  all  the  tuberculous  disease,  the 
plan  has  been  carried  out  of  removing  the  lower  end  of  the  vas  and  the 
corresponding  vesicula  seminalis  by  the  perineal  route,  while  the  other 
end  is  pulled  away  with  the  testis  through  an  incision  prolonged  into 
the  inguinal  canal.  Reverdin  and  other  surgeons  have  proved  that 
it  is  thus  possible  to  remove  the  whole  length  of  the  vas,  but  the  pro- 
ceeding is  one  of  considerable  difficulty  and  of  very  doubtful  value. 
The  perineal  part  of  the  operation,  conducted  through  a  curved  in- 
cision made  in  front  of  the  rectum  and  across  the  median  raphe,  is 
similar  to  and  even  more  difficult  than,  perineal  prostatectomy.  The 
■  vas  and  vesicula  have  to  be  reached  at  the  bottom  of  a  deep  and  nar- 
row wound,  there  is  apt  to  be  most  troublesome  venous  hemorrhage, 
and  there  is  some  risk  of  damaging  the  bladder  wall  (to  which  the 
vesicula  is  closely  bound  by  the  rectovesical  fascia)  or  the  ureter.  Fi- 
nally, the  wound  is  placed  very  badly  for  aseptic  purposes.  To  drag 
the  greater  part  of  the  vas  deferens  out  through  the  inguinal  canal  is 
also  a  rough  and  hazardous  procedure.  When  it  is  added  that  tubercu- 
lous disease  of  the  vesical  neck  or  prostate  is  often  present  with  dis- 
ease of  the  vas  deferens,  and  that  spontaneous  recovery  from  both  is 
not  infrequent,  the  arguments  in  favor  of  combined  perineal  and  in- 
guinal operations  are  seen  to  be  but  feeble.  The  operation  was  described 
in  the  "Gazette  des  Hopitaux, "  October  15,  1898,  and  also  in  the 
"Bull,  de  la  Soc.  Anatomique,"  1898,  p.  603. 

Erasion  of  the  Tuberculous  Epididymis. — In  removing  the 
whole  organ  the  surgeon  is  often  taking  much  more  than  is  actually 
diseased,  for  in  the  majority  of  cases  the  testis  proper  will  be  found 
to  be  free  from  tubercle.  It  is  the  epididymis  and  the  vas  which  are 
involved  with  so-called  "crude  tubercle,"  while  occasionally  the  testis 
becomes  affected  with  miliary  deposit.  Hence  a  very  thorough  erasion 
and  excision  of  all  the  tuberculous  foci  will  often  suffice,  and  the  tes- 
tis itself  may  be  safely  retained.  We  have  known  cases  in  which  the 
whole  epididymis  and  several  inches  of  diseased  vas  deferens  were  ex- 
cised, the  testis  remaining  for  years  of  normal  consistence  and  size. 
Some  importance  is  to  be  attached  to  the  retention  of  the  "internal 
secretion"   of  the   testis. 

The  erasion  must  be  effected  through  a  free  incision,  the  testis 
being  turned  out  and  the  tunica  vaginalis  being  laid  open.     Every 


OPERATIONS   UPON  THE   RECTUM,    ETC.  297 

particle  of  tuberculous  tissue  should  be  cut  or  scraped  away,  and  if 
the  vas  is  diseased,  it  also  should  be  dealt  with.  Care  should  be  taken 
not  to  damage  the  main  vessels  of  the  cord,  and  if  this  be  avoided,  the 
hemorrhage  will  only  be  slight.  Finally,  the  testis  and  its  vessels  are 
replaced  in  the  scrotum,  and  a  small  drainage-tube  left  in  the  wounfl 
for  a  few  days. 

After-treatment. — The  scrotum  is  well  slung  up  by  a. light  roll 
of  loose  gauze  appHed  as  a  suspender.  This  gauze  clings  to  the  skin 
better  than  any  other  dressing.  The  wound  may  be  then  dressed 
with  a  sponge  dusted  with  iodoform,  or  with  a  pad  of  Tillmann's  dress- 
ing packed  all  around  with  gauze,  and  secured  by  means  of  a  T-bandage 
or  a  spica.  If  this  be  properly  applied,  the  sponge  or  pad  exercises 
firm  but  gentle  pressure  upon  the  wound.  The  drainage-tube  should 
be  removed  in  twenty- four  hours,  and  the  dry  dressing  continued. 
In  the  first  twenty-four  hours  after  the  operation  retention  of  urine 
may  exist.  The  scrotum  is  easily  inflamed  by  the  use  of  irritant  lotions 
— e.  g.,  strong  carbolic  solutions. 

Should  suppuration  occur,  constant  care  must  be  taken  to  prevent 
bagging.  The  sutures  are  removed  on  the  fifth  to  the  seventh  day. 
The  patient  will  probably  complain  of  the  hard,  tender  swelling  which 
usually  appears  at  the  external  ring,  and  which  is  due  to  inflammatory 
changes  in  the  stump  of  the  cord.  As  the  wound  heals,  the  cicatrix 
becomes  depressed,  from  the  obliteration  of  the  scrotal  pouch.  If 
primary  union  be  not  obtained,  the  edges  of  the  wound  may  need  to 
be  retained  in  contact  by  strapping. 

Comment. — In  some  cases  the  descent  of  a  hernia  after  castra- 
tion has  forced  open  the  wound,  the  rupture  having  been  previously 
kept  up  by  the  enlarged  testicle.  During  the  operation,  moreover, 
hernial  sacs  have  been  inadvertently  opened  up.  If  a  scrotal  hernia 
exists,  the  rupture  should  be  reduced,  the  sac  excised,  and  its  neck 
ligated,  the  same  as  for  the  radical  cure  of  hernia. 


HYDROCELE. 

Open  Method  of  Treatment. — ^An  incision  through  the  skin  and 
into  the  tunica  vaginalis,  preferably  suprascrotal  or  in  the  lower  in- 
guinal region,  sufficiently  large  to  permit  the  introduction  of  drainage, 
is  made,  and  before  the  escape  of  all  the  fluid  the  cavity  is  packed 
gently  with  iodoform  gauze  as  high  up  toward  the  external   ring  as 


290  POSTOPERATIVE    TREATMENT. 

possible.  A  small  gauze  drain  is  also  introduced  downward  into  the 
scrotum,  over  which  the  ordinary  dressings  are  applied  and  held  in 
place  by  -a  suspensory  bandage.  The  gauze  drainage  after  the  fourth 
day  is  gradually  removed  and  the  wound  allowed  to  heal  by  granu- 
lation in  from  seven  to  ten  days. 

CIRCUMCISION. 

After-treatment  (Cheyne). — ^When  the  separation  of  the  pre- 
puce from  the  glans  does  not  give  rise  to  a  raw  surface,  after  using 
fine  catgut  sutures,  the  simplest  plan  is  to  dry  the  line  of  incision,  lay 
a  little  salicylic  wool  over  it,  and  fix  it  in  position  with  flexible  collodion, 
which  dries  quickly  and  may  be  left  for  a  week.  The  patient  should 
then  be  placed  in  a  sitz-bath  about  a  quarter  of  an  hour  before  the 
surgeon's  visit.  The  dressings  may  then  be  peeled  off  without  caus- 
ing much  pain.  Any  raw  surface  remaining  may  have  a  small  fresh 
dressing  applied  to  it.  However,  when  the  surface  of  the  glans  is  left 
raw,  a  better  method  is  to  wind  a  strip  of  wet  boric-acid  lint  around 
the  line  of  union,  while  outside  of  this  a  large  layer  of  wet  boric-acid 
lint  is  applied,  so  as  to  cover  the  whole  penis  and  scrotum,  and  this  is 
covered  with  oiled  silk  or  jaconet  and  kept  in  position  by  a  T-bandage. 
The  outer  dressing  is  changed  repeatedly  for  several  days  until  the  parts 
are  healed.  After  the  first  three  days  the  inner  layer  of  boric-acid 
lint  may  be  soaked  off  and  a  narrow  strip  saturated  with  boric-acid 
ointment  may  be  applied  in  its  place.  If  silk  or  other  nonabsorbable 
sutures  are  used,  they  may  be  removed  on  the  fifth  to  the  seventh  day. 

Bransford  Lewis'  method  of  after-treatment,  which  we  have  em- 
ployed several  times  with  success,  is  as  follows:  After  cleansing  and 
drying  the  penis,  it  is  encircled  loosely  with  a  piece  of  cotton  inclosed 
in  a  layer  of  gauze.  This  is  then  thoroughly  saturated  with  compound 
tincture  of  benzoin  applied  with  a  medicine-dropper.  On  drying, 
this  dressing  becomes  moderately  firm,  forming,  as  it  were,  an  anti- 
septic splint.  A  Teufel  support  bandage  is  put  on,  which  holds  the 
dressings  in  good  position.  The  dressing  is  renewed  after  three  to 
five  days.  In  eight  days  the  parts  are  usually  securely  healed  and 
all  dressings  are  removed,  except  possibly  some  mild  dry  dusting- 
powder.  With  this  form  of  dressing  in  adults  it  is  not  necessary  for 
the  patient  to  suspend  work  or  lay  up  after  the  operation,  but  they 
are  directed  to  continue  in  their  usual  employment. 


CHAPTER  XIV. 
MISCELLANEOUS  OPERATIONS. 


CHAPTER  XIV. 
MISCELLANEOUS  OPERATIONS. 

LIGATION  OF  ARTERIES. 

Operations  for  ligation  of  arteries  arc  usually  performed  under 
strict  asepsis,  and  under  such  circumstances  the  after-treatment  of 
the  wound  presents  nothing  different  from  ordinary  aseptic  wound 
treatment.  In  case  of  the  main  artery  of  an  extremity,  the  limb  should 
be  kept  absolutely  at  rest  and  be  a  little  raised.  The  arm  should  lie 
outstretched  upon  a  pillow,  the  lower  limb  raised  upon  an  inclined 
plane.  The  whole  extremity  is  enveloped  in  cotton  wool  and  is  kept 
warm  by  hot  bottles.  In  case  vessels  the  size  of  the  iliacs,  the  sub- 
clavian, or  the  common  femoral  are  ligated,  absolute  rest  should  be 
enforced  for  a  period  of  not  less  than  twenty-one  days. 

The  time  involved  in  the  after-treatment  of  cases  in  which 
smaller  vessels  have  been  ligated  may  be  regulated  in  proportion.  The 
period  of  compulsory  rest  should  be  longer  in  old  subjects  than  in  the 
young,  and  in  cases  in  which  the  lower  limb  is  concerned  than  in  the 
upper. 

ABSCESSES. 

General  Considerations. — ^When  pus  collects  in  any  cavity  or 
new  formation  in  the  body,  in  a  recognized  quantity,  such  collection 
is  calLed  an  abscess.  If  it  be  well  defined,  held  in  position  by  a  limited 
wall  or  membrane,  it  is  a  "circumscribed  abscess,"  and  when  infil- 
trated in  the  tissues  it  is  called  "diffuse."  A  rapid  recent  collection 
of  pus  is  called  an  acute  abscess,  a  slow-forming  or  chronic  collection, 
with  little  or  no  inflammatory  reaction,  is  called  a  cold  abscess.     (Wyeth.) 

The  distinct  characteristics  of  the  various  sorts  of  abscesses  depend 
upon  the  character  of  the  pus  and  the  location  or  character  of  tissue 
in  which  they  are  formed.  The  amount  of  pain  in  purulent  inflamma- 
tion differs  greatly :  in  some  cases  it  is  intense,  in  others  entirely  absent, 
depending  largely  upon  the  tissues  or  amount  of  nerves  in  the  part 
affected.  The  amount  of  pain  also  depends  upon  the  rapidity  with 
which  the  abscess  forms.  If  the  pus  accumulates  rapidly,  the  pain 
will  be  more  intense;  if  slowly,  the  tissues  become  accustomed  to 
the  distention. 


302  POSTOPERATIVE    TREATMENT. 

General  impairment  of  the  circulation,  general  anemia,  or  other 
systemic  conditions — -such,  for  instance,  as  diabetes — increase  the 
tendency  to  suppuration  and  markedly  interfere  with  recovery. 

General  Treatment. — When  acute  abscess  exists,  whether  cir- 
cumscribed or  diffuse,  it  should  be  freely  evacuated.  The  point  of 
greatest  importance  is  to  have  the  opening  or  openings  in  such  position 
that  drainage  from  the  most  dependent  portion  of  the  cavity  is  accom- 
plished. Thorough  drainage  is  indispensable.  So  soon  as  the  ab- 
scess is  opened  the  cavity  should  be  thoroughly  but  gently  irrigated 
with  a  solution  of  i  :  3000  mercuric  chlorid,  lysol  i  percent,  or  a 
saturated  solution  of  boric  acid,  after  which  rubber  or  gauze  drainage 
should  be  inserted,  the  treatment  thereafter  being  similar  to  that  of 
open  treatment  of  septic  wounds.  It  should  be  remembered,  however, 
that  gauze  drains  pus  but  poorly,  and  in  many  instances  a  rubber 
tube  for  drainage  is  better. 

Tuberculous  or  cold  abscess,  in  case  there  is  no  deformity  or  marked 
discomfort  to  the  patient,  may  be  left  unopened.  When  for  any  reason 
it  is  considered  best  to  incise  a  tuberculous  abscess,  it  should  be  per- 
formed under  the  most  strict  asepsis,  and  the  cavity,  partly  filled  with 
an  emulsion  of  iodoform  and  glycerin,  should  then  be  closed  and  her- 
metically sealed. 

Some  surgeons  prefer  to  evacuate  all  tuberculous  abscesses  with  an 
aspirator  instead  of  incision.  When  this  is  carefully  done  to  the  ex- 
clusion of  air,  particularly  in  small  abscesses,  and  with  the  thorough 
cleansing  of  the  abscess,  constitutional  disturbance  is  rare.  Should, 
however,  inflammation  and  suppuration  follow,  free  incision  should 
be  practised  and  thorough  drainage  established. 

Pulmonary  Abscess. — Incision  and  Drainage. — Where  the 
visceral  and  parietal  layers  of  the  pleura  are  not  adherent,  the  sim- 
plest way  of  securing  approximation  of  the  two  layers  is  to  unite  them 
by  a  series  of  local  stitches,  the  same  as  is  employed  in  ordinary  needle- 
work. Fine  catgut  sutures  should  be  used,  and  these  should  be  in- 
serted before  the  pleura  is  opened.  As  a  rule,  however,  the  lung  is 
consolidated  in  cases  of  pulmonary  abscess  and  the  tissue  so  adherent 
that  they  do  not  fall  away  from  the  fixed  wall  to  any  material  extent. 
After  the  evacuation  of  the  pus  the  cavity  should  be  swabbed  out  with 
a  solution  of  zinc  chlorid  (40  grains  to  the  ounce).  A  large-sized 
drainage-tube  should  then  be  introduced  into  the  cavity,  and  packed 
fairly  firmly  around  with  iodoform  gauze.     The  tube  should  be  large 


MISCELLANJOOUS     Oi'l'.RATIONS.  3O3 

enough  to  exert  sullieient  pressure  from  the  lung  tissue  surrounding 
it  to  check  oozing.  The  wound  is  left  open  and  a  large  dressing  applied. 
The  tube  should  be  left  in  position  three  or  four  days,  until  its  track 
is  well  established;  it  should  then  be  removed,  washed,  and  replaced, 
or  a  gauze  drainage  substituted  therefor.  The  abscess  cavity  should 
not  be  irrigated,  but  insufflation  of  iodoform  or  boric-acid  powder 
may  be  practised  at  each  dressing.  The  tube  or  drainage  should  be 
retained  until  the  discharge  is  mucoid  in  character  and  all  expectora- 
tion has  ceased.  It  is  important  always  to  secure  the  drainage-tube 
in  position  by  means  of  a  safety-pin,  lest  it  slip  into  the  pleural  cavity 
and  necessitate  an  additional  operation.  Neglect  that  would  lead 
to  such  disastrous  results  is  little  short  of  criminal,  but  instances  in 
which  this  has  occurred  are  too  plentiful. 

Retrorectal  Abscess. — ^A  semicircular  incision  between  the  anus 
and  coccyx  is  the  best  in  these  cases.  After  thorough  evacuation  the 
pus-cavity  should  be  washed  out  with  hydrogen  dioxid,  followed  by 
I  :  2000  mercuric  chlorid  solution.  The  sphincter  should  always  be 
stretched  after  the  abscess  cavity  is  evacuated  and  the  stools  kept 
regular  but  not  loose.  As  to  drainage  for  these  cases,  a  double  rubber 
tube  is  preferable  to  gauze.  Frequent  irrigation  with  antiseptic  solutions 
is  very  important.  If  the  abscess  wound  exhibits  a  sluggish  tendency 
and  the  abscess  does  not  heal  as  rapidly  as  the  general  condition  would 
indicate,  the  tube  should  be  removed  and  the  cavity  swabbed  out  with 
95  percent  carbolic  acid  or  pure  ichthyol.  If  the  latter  is  used,  the 
better  plan  is  to  saturate  a  narrow  strip  of  gauze  with  the  drug,  which 
is  then  introduced  into  the  cavity  and  left  for  two  or  three  hours.  It 
should  then  be  removed  and  the  drainage-tubes  introduced.  Patients 
may  be  allowed  to  walk  or  stand  upon  their  feet,  but  sitting  should 
not  be  allowed  until  the  abscess  has  practically  healed,  as  this  posture 
interferes  materially  with  the  circulation  and  drainage  of  the  parts. 
Tonics,  good  nourishing  diet,  and  such  medication  as  seems  indicated 
should  be  employed. 

Psoas  Abscess. — In  the  method  of  Sir  Frederick  Treves  a  tube 
of  a  Leiter's  irrigator  is  introduced  into  the  center  of  the  abscess,  and, 
the  cistern  being  placed  at  a  height  of  four  to  six  feet  above  the  level 
of  the  table,  a  large  stream  of  the  mercurial  solution  or  warm  water 
is  allowed  to  run  through  the  abscess.  During  this  process  of  irriga- 
tion the  abscess  is  frequently  emptied  by  pressure  applied  to  it  from 
the  front,  and  is  allowed  to  till  again  and  to  be  emptied  again.     The 


304  POSTOPEEATIVE    TREATMENT. 

patient's  position,  also,  is  altered  many  times.  He  is  turned  over  toward 
the  sound  side,  and  is  then  turned  almost  upon  the  back,  in  order 
that  every  part  of  the  abscess  sac  may  be  well  and  vigorously  flushed. 

The  surgeon  now  proceeds  to  remove  as  much  of  the  lining  mem- 
brane of  the  abscess  as  is  possible.  The  finger  is  the  safest  and  most 
useful  instrument.  It  is  introduced  as  far  as  possible.  Diverticula 
from  the  main  abscess  are  opened  up,  collections  of  caseous  matter 
are  scraped  away  with  the  nail,  and  here  and  there  the  action  of  the 
finger  may  be  helped  by  a  sharp  spoon.  This  instrument,  however, 
must  be  used  with  caution.  It  causes  bleeding,  and  often  produces 
a  needlessly  extensive  raw  surface.  Moreover,  the  anterior  wall  of 
the  abscess  cavity  is  usually  thin,  and  the  steel  instrument  may  inflict 
a  serious  injury  upon  that  part  of  the  parietes. 

Next  to  the  finger,  the  most  valuable  means  of  clearing  out  the 
abscess  cavity  is  a  piece  of  fine  Turkey  sponge  held  in  a  slender,  long- 
bladed  holder.  This  should  be  passed  in  all  directions  over  every 
part  of  the  abscess  wall.  The  wall  should  be  literally  scrubbed  with 
it.  It  should  be  gently  bored  by  a  rotatory  movement  into  every 
pocket  and  diverticulum.     The  sponge  must  be  changed  very  frequently. 

After  a  vigorous  use  of  the  finger  and  sponge,  the  irrigator  is  again 
brought  into  action,  and  the  abscess  cavity  is  once  more  flushed  out, 
and  such  debris  as  the  sponge  has  left  is  swept  away.  Once  again 
the  finger  and  thumb  search  out  all  the  recesses  of  the  abscess,  and 
once  again  the  stream  from  the  irrigator  follows.  This  is  done  until 
the  abscess  cavity  appears  to  be  clean,  and  until  the  sponge  is  returned 
practically  unsoiled.  The  process  is  slow  and  tedious,  but  it  is  very 
effectual.  It  leaves  the  abscess  cavity  bare,  and  freed  entirely  of  the 
curdy  pus,  of  the  caseous  masses,  and  of  the  ill-conditioned  debris 
which  filled  it. 

Finally,  the  interior  of  the  abscess  is  wiped  dry  with  the  last  set  of 
sponges  used,  and  the  wound  is  closed  by  a  series  of  silkworm-gut  su- 
tures, passed  sufficiently  deep  to  include  the  greater  part  of  the  muscu- 
lar and  tendinous  structures  with  the  skin. 

A  pad  of  dry  gauze  or  of  wool  dusted  with  iodoform  is  placed  over 
the  little  wound,  and  is  secured  in  position  by  a  broad  flannel  bandage. 

After-treatment. — The  subsequent  treatment  consists  in  abso- 
lute rest  in  the  recumbent  position  for  a  period  of  months — a  period 
which  may  easily  be  too  short,  but  hardly  too  long.  The  actual  number 
of  months  during  which  the   recumbent   posture   should  be  observed 


MISC:iOLLANEOUS    OPERATIONS.  305 

must  depend  u[)on  the  nature,  extent,  and  stage  of  the  disease.  In 
adults  it  will  probably  extend  beyond  six  months  in  the  hands  of  those 
who  wish  to  exercise  a  wise  caution.  It  is  not  the  abscess  which  is  in 
need  of  treatment — it  is  rather  the  diseased  condition  which  has  pro- 
duced it. 

•  If  the  period  of  rest  can  be  carried  out  at  the  seaside,  and  the  patient 
spend  the  greater  part  of  the  time  out  in  the  open  air  (winter  and  sum- 
mer) in  a  spinal  carriage,  so  much  the  better. 

The  abscess  may  refill,  and  may  need  to  be  evacuated,  washed  and 
scrubbed  out,  and  closed  a  second  time. 

In  no  case  have  I  had  occasion  to  carry  out  a  third  operation.  If 
the  wound  should  break  down  and  pus  escape  at  the  site  of  the  incision, 
free  drainage  and  a  most  liberal  irrigation  must  be  the  plan  of  treatment. 
This  has  occurred  in  a  few  of  my  cases,  and  in  every  instance  the  pa- 
tients who  have  been  the  subject  of  this  complication  have  done  well. 
The  wound,  even  in  these  cases,  will  heal  by  first  intention,  and  signs 
of  pus  beneath  the  surface  will  usually  not  be  observed  until  a  fortnight 
or  more  has  passed  by. 

Barker  has  employed  in  these  cases  an  ingenious  instrument,  which 
he  terms  the  hollow  or  flushing  curet.  It  consists  of  a  curet  with  a 
tubular  handle  and  shaft,  through  which  water  can  be  conducted  into 
the  hollow  of  the  curet.  The  water,  running  continuously  through  the 
instrument,  washes  away  all  debris  as  soon  as  it  is  loosened  by  the 
sponge. 

Technic. — The  modus  operandi  is  thus  described* :  A  two-inch  inci- 
sion is  made  through  sound  structures  over  the  lower  end  of  the  swelling. 
Through  this  opening  a  hollow  gouge  is  inserted,  which  is  connected 
with  a  reservoir  of  hot  water  at  105°  to  110°  by  a  rubber  tube  some  six 
feet  long.  This  reservoir  (a  three-gallon  can)  is  raised  about  five  feet 
above  the  operating  table.  When  the  water  is  now  turned  on,  it  rushes 
through  the  long  gouge  to  the  fundus  of  the  abscess  with  considerable 
force,  and  the  reflux  carries  the  contents  of  the  cavity  out  by  the  incision. 
By  gentle  scraping  with  the  flushing-scoop  the  more  solid  caseous  mat- 
ter is  dislodged,  the  hot  water  carrying  it  clear  of  the  cavity  at  once. 
Then  the  walls  of  the  cavity  are  gently  scraped  in  a  methodic  manner 
until  the  soft  lining  is  loosened  and  carried  away  from  every  part  of  the 
abscess.     In  order  to  effect  this  thoroughly,  the  scoops  are  made  of 

*  "  Brit.  Med.  Jour.,"    Feb.  7,  1S91. 


3o6  POSTOPERATIVE    TREATMENT. 

varying  length,  so  that  the  deeper  parts  can  be  reached.     With  hot 
water  the  bleeding  is  but  slight  if  the  peeling  be  done  cautiously. 

When"  the  water  runs  out  clear  after  having  been  carried  to  all  the 
recesses  of  the  cavity,  the  instrument  is  withdrawn.  Then  any  excess 
of  water  is  squeezed  out;  and  if  the  deeper  parts  are  accessible,  sponges 
are  used  to  dry  out  the  last  traces  of  moisture.  Then  two  or  three  ounces 
of  fresh  iodoform  emulsion  is  poured  into  the  deepest  part  of  the  ab- 
scess, and  stitches  are  inserted  in  the  edges  of  the  incision.  Before 
these  are  knotted,  all  excess  of  emulsion  should  be  squeezed  out  of  the 
cavity.  The  knotting  of  the  silk  sutures  then  completes  the  procedure. 
As  no  drain-tube  is  used,  a  simple  dry  dressing  of  salicylic  wool  is  alone 
required;  but  it  should  be  laid  on  in  considerable  quantity,  so  as  to 
exert  elastic  pressure  over  the  whole  area  of  the  abscess  when  bandaged. 
Such  a  dressing  may  be  left  on  for  about  ten  days,  when  it  is  time  to 
remove  the  stitches,  and  the  wound  should  then  be  firmly  healed. 
A  piece  of  salicylic  wool  secured  by  collodion  at  the  edges  should,  how- 
ever, be  laid  over  it,  to  keep  it  from  chafing,  for  a  few  days  longer,  and 
the  elastic  pressure  also  should  be  kept  up. 

BUBO. 

Technic. — When  suppuration  is  marked,  the  pus  should  be  evacuated 
by  free  incision,  and  at  the  same  time  all  portions  of  the  glandular  struc- 
ture should  be  removed  by  means  of  careful  dissection  or  a  sharp  curet. 
The  wound  is  left  open  and  packed  with  iodoform  gauze  and  allowed 
to  heal  by  granulation.  It  requires  from  two  to  four  weeks  ordinarily 
for  the  wound  to  heal. 

Considerations  of  Time. — Surgeons  disagree  as  to  the  proper  time  of 
extirpating  or  incising  the  gland.  The  majority  prefer  to  wait  until 
suppuration  is  well  marked  and  the  gland  is  entirely  broken  down  be- 
fore any  incision  is  made.  For  this  reason  Krulle  advises  the  applica- 
tion of  hot  fomentations  till  the  gland  is  entirely  broken  down,  when 
the  pus  is  evacuated  through  a  small  incision.  Every  second  day  the 
pus  is  then  squeezed  out  and  the  cavity  of  the  wound  washed  with  a  i 
percent  solution  of  silver  nitrate.  Under  this  treatment  the  patient  can 
walk  about  and  thus  avoid  the  necessity  of  lying  in  bed.  This  method 
is  only  applicable  to  cases  in  which  the  glands  break  down  rapidly,  but 
in  many  instances  suppuration  goes  on  slowly,  in  which  case  it  is  better 
to  make  a  free  incision,  evacuate  the  pus,  and  remove  by  curetment  the 
broken-down  remains  of  the  gland.     When  healing  is  delayed,  general 


MISCELLANEOUS    OPIIKATIONS. 


307 


tonics  arc  indicated,  and   the  local   use  of  balsam  of   I'cru  or  ichlhyol 
applied  upon  the  gau/e  packing  may  prove  of  great  benefit. 

Hayden  waits  until  pus  forms,  then  through  a  small  incision  squeezes 
out  the  pus,  washes  the  cavity  out  with  hydrogen  peroxid,  then  flushes 
out  with  a  bichlorid  solution,  injects  warm  iodoform  ointment,  and 
dresses  with  cold  moist  bichlorid  gauze  to  congeal  the  ointment. 

EXCISION  OF  THE  GASSERIAN  GANGLION. 

Postoperative  Treatment. — In  a  prolonged  and  difficult  operation  of 
this  kind  faults  in  asepsis  are  apt  to  creep  in,  as  shown  by  the  fact  that 


SENSOR/  ROOT 
MOTOR    ROOT 


AUmCULO  TCMPDRM  N 


Fig.  76. — Showing  Locatiox  of  Gasseriax  Ganglion. — {Holdcn.) 

about  half  the  fatal  results  are  due  to  septic  meningitis.  At  the  end  of 
the  operation,  therefore,  the  wound  should  be  gently  flushed  with  a 
weak  warm  antiseptic  solution.  There  is  always  much  oozing  during 
the  operation,  and  nothing  could  be  worse  than  the  collection  of  blood 


3o8 


POSTOPERATIVE    TREATMENT. 


between  the  dura  and  the  flap.  Hence,  whether  the  large  trephine 
has  been  used  or  the  osteoplastic  method,  provision  should  be  made 
for  drainage  during  the  first  forty-eight  hours,  and  the  patient's  head 
should  be  turned  on  the  affected  side.  A  small  piece  of  iodoform  gauze, 
removed  in  two  days'  time,  will  suffice.  The  head  must  be  enveloped 
in  a  light  dressing  of  sterilized  gauze  and  wool,  and  for  securing  it 
an  elastic  bandage  is  useful,  or  a  modified  Barton  or  recurrent  bandage 
(Wharton)  may  be  employed. 

The  wound  should  heal  in  a  week;  but  if  bone  has  been  replaced 
or  the  osteoplastic  method  employed  (see  Fig.  77),  it  may  happen  that 
necrosis  will  occur.     If  the  ganglion  is  removed  by  avulsion  or  otherwise, 


Fig.  77. — Osteoplastic  Flap  Turned  Down,  showing  Dura  Mater,  Meningeal 
Artery,  Exposing  Gasserian  Ganglion,  etc. — {Brewer.) 


it  not  only  severs  connection  between  the  root  and  the  second  and  third 
divisions,  but  also  between  the  root  and. the  first  division  as  well.  It 
then  follows  that  the  eye  will  be  anesthetic,  dryness,  friction,  and  foreign 
bodies  are  not  perceived,  and  abrasion,  corneal  ulceration,  and  loss  of 
the  eye  may  follow.  Keen  says  to  avoid  this  just  before  the  operation 
is  begun  it  is  best  to  sew  the  eyelids  together  to  protect  the  ball,  the  su- 
tures being  removed  on  the  third  day.  A  celluloid  shield,  similar  to  the' 
vaccination  shield,  and  devised  by  Keen,  is  then  fastened  in  front  of  the 
eye  by  elastic,  and  is  worn  for  a  week  or  more,  the  eye  being  syringed 
daily  with  a  warm  boric  solution. 

For  this  reason,  and  also  on  account  of  the  success  of  the  operation. 


MISCELLANEOUS    OPERATIONS.  309 

limited  to  the  two  main  divisions  of  the  fifth  nerve  anrl  the  ganglion, 
the  operator  is  advised  to  let  the  ophtiialmic  trunk  and  the  ganglion 
alone;  if  this  advice  be  followed,  no  precautions  are  required  as  regards 
the  eye. 

Postoperative  shock  may  be  considerable  in  these  patients,  who 
are  usually  aged  and  exhausted  by  their  suffering,  and  it  has  accounted 
for  nearly  half  of  the  deaths  recorded.  In  overcoming  it,  adrenalin 
and  strychnin  injections,  brandy  and  coffee  enemas,  and  a  warmth  to 
the  general  surface  are  the  chief  remedies. 

LAMINECTOMY. 

In  closing  the  wound  when  the  cord  has  been  exposed  some  surgeons 
prefer  not  to  close  the  theca  or  outer  covering  of  the  cord,  but  leave  it 
open  in  order  to  prevent  pressure.  If  carefully  sutured,  however,  it 
tends  to  prevent  loss  of  cerebrospinal  fluid,  and  if  left  open  cicatricial 
adhesions  of  the  soft  parts  to  the  surface  of  the  cord  may  occur.  A 
drainage-tube  is  usually  placed  in  the  muscular  portion  of  the  wound 
to  carry  off  the  wound  fluids  for  the  first  twenty-four  to  thirty-six  hours. 
Unless  for  very  urgent  reasons  the  drainage-tube  should  not  remain 
longer.  The  muscles  and  subcutaneous  tissues  are  usually  approximated 
by  buried  sutures,  and  skin  closed  by  silkworm-gut,  and  the  usual 
antiseptic  dressings  applied  and  held  in  place  by  ordinary  binders. 

The  position  of  the  patient  after  the  operation  should  be  dorsal, 
which  affords  sufficient  drainage  and  prevents  escape  of  the  cerebro- 
spinal fluid.  The  limbs  and  body  are  elevated,  and  borated  starch  or 
zinc  stearate  should  be  liberally  applied  should  the  fluid  discharges 
irritate  the  skin. 

After-treatment. — -On  account  of  the  abundant  oozing  both  of  the 
wound-fluids  and  possibly  of  the  cerebrospinal  fluid,  the  wound  will 
usually  -have  to  be  dressed  within  the  first  twelve  hours,  but  after 
the  first  twenty-four  hours  not  usually  more  than  once  in  two  or  three 
days.  The  strictest  antisepsis  should  be  observed,  lest  infection 
should  follow.  This  is  particularly  necessary,  both  during  the  oper- 
ation and  the  after-treatment,  if  there  are  bed-sores,  since  they- pro- 
duce considerable  foul  discharge  which  may  infect  the  wound.  If  the 
patient  has  lost  control  of  the  bladder  and  bowels,  an  additional  source 
of  infection  exists,  which  will  require  great  vigilance. 

Thorburn  has  proposed  to  drain  the  bladder  by  suprapubic  cystot- 
omy after  injury  of  the  cord,  to  avoid  the  constant  wetting  of  the  wound, 


3IO 


POSTOPERATIVE    TREATMENT. 


and  its  infection  through  the  incontinence  of  the  urine.  The  supra- 
pubic route  is  selected,  inasmuch  as  these  parts  are  not  anesthetic  and 
therefore  not  apt  to  slough.  The  suggestion  seems  to  be  very  reason- 
able, but  I  have  seen  no  report  of  it  having  been  carried  into  practice. 
The  bed-sores  should  be  dressed  with  boric  ointment,  carbolated  vaselin, 
or  such  other  mild  ointments.  They  often  show  very  remarkable  and 
early  improvement,  and  not  uncommonly  heal  entirely.     Of  course, 


Fig.  78. — Spina  Bifida  (Original). — {"American  Text-hook  of  Surgery") 

the  usual  precautions  as  to  food  and  drink  must  be  observed,  together 
with  the  use  of  opiates  for  sleep  and  such  other  symptomatic  treatment 
as  may  be  required.     (Dennis.) 


SPINA  BIFIDA. 
The  radical  cure  of  spina  bifida  is  now  more  frequently  attempted 
than  formerly.     The  choice  of  methods  for  removal  of  the  tumor  by 
dissection,  ligation,  or  excision  must  depend  upon  the  size,  local  condi- 


MISCELLANEOUS   OPERATIONS.  311 

tion  of  the  formation  or  growth,  anrl  the  general  condition  of  the  child. 
If  the  tumor  is  large  or  the  cord  or  cauda  equina  is  involved,  usually  no 
attempt  at  removal  should  be  made.  Pedunculated  cysts,  where  the 
opening  in  the  lamina  is  small,  may  be  safely  removed.  After  removal 
or  extirpation  a  double  layer  of  iodoform  gauze  is  placed  over  the  wound, 
after  which  the  entire  wound  and  area  well  around  the  incision  should  be 
hermetically  sealed  by  means  of  collodion  and  cotton.  Over  this  at 
least  two  layers  of  rubber  tissue  should  be  placed  and  sealed  to  the  skin 
about  its  edges  with  chloroform,  and,  lastly,  over  all  a  layer  of  cotton  is 
placed,  v^ith  plain  gauze,  and  all  held  in  position  by  a  broad  abdominal 
bandage. 

The  after-treatment  of  these  cases  is  of  vital  importance.  The 
child  is  placed  in  bed  upon  its  stomach,  with  no  pillow  under  the 
head.  This  position  should  be  maintained  for  several  days  or  weeks, 
or  until  thorough  healing  has  so  far  progressed  that  all  leakage  of  cere- 
brospinal fluid  has  ceased.  Excessive  loss  of  cerebrospinal  fluid  is 
manifested  by  sinking  of  the  fontanels. 

Nourishment  with  alcoholic  stimulants  should  be  administered 
freely,  as  death  from  exhaustion  is  of  very  frequent  occurrence.  De- 
pressed fontanel,  tetanic  convulsions,  however  slight,  preceded  by 
vomiting,  usually  indicate  a  fatal  termination. 

HYPOSPADIAS  OR  ECTOPIA  VESICA. 

General  Considerations. — Parker  keeps  his  patients  in  a  hip-bath 
of  warm  boric  lotion  throughout  the  whole  of  the  after-treatment,  with 
the  result  that  almost  complete  primary  union  follows  a  flap  operation. 
With  care  the  position  of  the  patient  in  a  hip-bath  may  be  made  so  com- 
fortable that  he  will  rest  better  in  the  bath  than  in  the  constrained  and 
cramped  position  he  must  of  necessity  occupy  in  bed.  The  discomfort 
of  lying  upon  a  wet  mackintosh  is  also  not  inconsiderable. 

It  is  needless  to  say  that  the  lotion  in  the  bath  must  be  maintained 
at  an  even  temperature,  and  be  constantly  changed.  Thiersch  and 
others  advise  the  use  of  a  Compress  *  after  the  operation  has  been 
quite  completed.  This  instrument  is  intended  to  occlude  the  newly 
made  urethra,  and  to  be  removed  when  required. 

It  cannot  be  recommended,  on  these  grounds :  in  the  first  place,  the 
capacity  of  the  new  bladder  is  very  small;  and  in  the  second  place,  the 
constant  pressure  of  the  instrument  is  capable  of  producing  a  slough 
or  even  a  urinary  fistula. 

*  An  instrument  devised  for  making  pressure  over  the  new-made  urethra. 


312  POSTOPERATIVE    TREATMENT. 

In  the  most  successful  cases  a  urinal  cannot  be   dispensed  with. 

Results  of  the  Operation  Generally. — The  results  claimed  in  the 
most  successful  cases  are  that  the  raw  surface  of  the  bladder  is  protected 
and  covered  in,  and  that  a  urinal  can  be  worn  which  will  keep  the 
patient  quite  dry.  Many  patients  are  free  from  the  inconvenience  of 
incontinence  when  they  are  lying  down,  but  in  no  instance  can  it  be 
claimed  that  the  patient  has  acquired  a  control  over  the  bladder. 
These  results,  however,  are  very  satisfactory  when  the  misera,ble  condi- 
tion of  the  patients  before  the  operation  is  considered.     (Treves.) 

SYMPHYSIOTOMY. 

General  Considerations. — After  the  completion  of  the  labor,  the 
wound  should  be  thoroughly  cleansed  with  sterile  water,  and  lastly  alco- 
hol. Three  or  four  stout  silk,  silver-wire,  extra  large  silkworm-gut, 
or  preferably  heavy  kangaroo  tendon  sutures  are  used  to  hold  in  appo- 
sition the  separated  bones.  The  sutures  should  be  inserted  at  least 
one-half  inch  from  the  margins  of  the  muscular  insertion,,  and  should 
include  all  the  fibrous  tissue  down  to  and  including  the  periosteum. 
They  are  tied  in  the  median  line,  cut  short,  or  buried.  The  superficial 
incision  may  then  be  closed  after  the  ordinary  method,  small  rubber 
tissue  drainage  being  indispensable. 

The  wound  is  dressed  with  several  layers  of  iodoform  cloth  with  a 
layer  of  Wood's  or  absorbent  cotton,  all  of  which  are  held  snugly  in  posi- 
tion by  means  of  a  broad  moleskin  adhesive  plaster  passing  around  the 
pelvis  immediately  below  the  crest  of  the  ilium,  and  extending  down  over 
the  trochanters  in  order  to  retain  the  pelvic  bones  in  apposition.  The 
patient  is  now  placed  upon  a  gutter-shaped  bed  or  mattress,  with  cush- 
ions under  the  lateral  halves  of  the  body.  Jewett  and  others  adopt 
practically  the  same  method,  using  an  ordinary  hard  mattress  and  keep- 
ing the  patient  on  two  firm  cushions  placed  under  the  lateral  halves  of 
the  pelvis  and  extending  nearly  to  the  shoulders. 

Mechanical  Aids. — An  excellent  apparatus  for  maintaining  coap- 
tation of  the  pelvic  bones  after  symphysiotomy  is  Ayres'  hammock  bed. 
This  consists  of  a  canvas  stretcher  supported  as  shown  in  Fig.  79.  The 
stretcher  may  be  made  more  or  less  trough-like  by  adjustment  at  shorter 
or  longer  distances  apart  of  the  poles  on  which  it  hangs.  A  canvas  slide 
wide  enough  to  reach  well  above  and  below  the  pelvis  is  suspended  by 
its  ends  from  a  second  series  of  poles  above  the  first.  The  patient  rests 
with  her  pelvis  in  the  loop  of  the  sling,  while  the  remainder  of  her  body 


MISCELLANEOUS    OPERATIONS. 


313 


is  supported  by  the  stretcher.  It  will  be  seen  that  the  pubic  bones  are 
held  firmly  in  apposition  by  the  action  of  the  sling. 

The  author  has  used  an  ordinary  hospital  bed  with  high  frames  and 
woven  wire  mattress  to  accomplish  the  same  purpose.  The  stretcher 
bolts  of  the  mattress  in  the  center  are  loosened  with  an  ordinary  wrench. 
If  necessary,  the  two  outer  bolts  of  the  wire  mattress  may  be  drawn  very 
tight.  Over  this  is  placed  an  ordinary  cotton  mattress.  Two  poles 
are  then  adjusted  above  the  patient  similar  to  the  mechanism  of  the 
Ayres'  bed  (Fig.  79). 

When  the  bed-pan  is  used,  the  greatest  care  must  be  exercised  by  the 


Fig.  79. — Ayres'  Symphysiotomy  Hammock,  Showing  Patient. — {Jewett.) 


nurse  to  see  that  no  movement  of  the  bones  is  permitted.  The  sling  in 
which  the  patient  lies  should  not  be  removed,  but  the  thighs  may  be 
gently  lifted  while  the  nurse  slips  the  vessel  beneath.  The  patient 
should  remain  in  bed  fully  six  weeks,  the  case  being  treated  as  in  fracture 
of  the  pelvis.  The  pelvic  support  should  not  be  discarded  for  three  or 
four  months  after  the  woman  leaves  her  bed. 


314  POSTOPERATIVE    TREATMENT. 

TUBERCULOSIS  OF  THE  JOINTS. 

This  condition  is  characterized  by  slow  beginning,  by  its  usual  limi- 
tation to  one  joint,  by  the  tendency  to  fixation  of  the  joint,  and,  lastly, 
by  the  atrophy  of  the  muscles  both  above  and  below  the  affected  part. 
(Ochsner.) 

Rest  Cure. — It  is  of  the  utmost  importance  that  the  surgeon's  atten- 
tion be  primarily  directed  toward  the  improvement  of  the  patient's  gen- 
eral condition,  which  can  be  best  accomplished  by  improving  the  hy- 
gienic surroundings,  the  nutrition,  and  regulating  the  habits  of  life; 
and  by  administering  tonics  and  concentrated  foods  and  some  form  of 
creasote.  Above  all  things,  the  patient  should  not  be  permitted  to  con- 
tinue to  live  under  the  conditions  which  primarily  gave  rise  to  the  disease. 
These  points  are  of  great  importance,  not  only  in  obtaining  a  recovery 
from  immediate  disease,  but  also  for  the  purpose  of  securing  a  perma- 
nency of  cure.  It  frequently  becomes  necessary  to  change  the  dwelling 
of  these  patients,  if  not  the  climate,  to  change  their  food,  to  regulate 
their  hours  of  rest,  and  frequently  their  occupation. 

This  accomplished,  the  treatment  of  the  joint  involved  depends 
upon  its  location  and  the  extent  to  which  the  disease  has  progressed. 
If  in  the  incipient  stage,  rest  alone,  with  the  conditions  described  above, 
will  frequently  suffice  to  produce  a  recovery.     (Senn.) 

Mechanical  Aids. — A  light  cast  made  of  plaster-of-paris,  very  care- 
fully constructed  and  strengthened  by  thin  strips  of  wood-fiber,  is  usu- 
ally the  most  desirable  dressing,  unless  the  patient  can  afford  the  use  of 
similar  dressings  manufactured  from  aluminium.  The  cast  should  be  ap- 
plied over  some  elastic  woven  material  arranged  in  a  double  layer  in 
order  that  the  friction  of  the  cast  which  adheres  to  the  outer  layer  will 
not  be  directly  against  the  skin,  but  against  the  second  layer  which  will 
remain  free.  If  the  joint  of  the  ankle  or  knee  is  involved,  it  is  best 
to  draw  two  closely  fitting  stockings  upon  the  extremity.  The  cast 
should  be  worn  for  three  or  four  months  after  the  joint  is  apparently 
well.  In  the  case  of  a  hip-joint,  enforced  rest  by  fixation  with  a  plaster- 
cast  should  be  supplemented  by  the  use  of  a  weight-and-puUey  extension 
to  be  applied  at  night  for  a  period  of  at  least  two  years  after  the  joint 
has  apparently  fully  recovered,  for  the  reason  that  this  plan  of  treatment 
tends  to  prevent  recurrence.      (Ochsner.) 

This  also  tends  to  prevent  deformity,  to  increase  the  comfort  of  the 
patients,  and  to  remind  them  of  the  necessity  of  avoiding  traumatism 


MISCELLANEOUS    OPERATIONS.  31  5 

for  a  considerable  lime.  Extension  is  made  l>y  applyinjf  11  strip  of  i-ubl;(,-r 
adhesive  plaster  to  the  inner  and  outer  surface  of  the  entire  thigh  and 
leg,  holding  them  in  place  by  a  roller  bandage.  These  plaster  strips  arc 
attached  to  the  cord  which  passes  over  the  pulley  to  the  weight.  The 
lower  end  of  the  bed  should  be  elevated  sufficiently  to  secure  counter- 
extension  from  the  weight  of  the  body.  The  amount  of  weight  to  be 
employed  may  be  determined  best  by  the  comfort  of  the  patient. 

Operation  Upon  the  Joints. — After  the  diseased  bone  and  tissue 
has  been  completely  removed,  the  raw  surfaces  all  should  be  thoroughly 
and  repeatedly  swabbed  with  a  95  percent  solution  of  carbolic  acid  for 
a  period  of  five  minutes,  then  the  superfluous  acid  should  be  washed 
away  with  strong  alcohol.  After  this  it  is  the  custom  of  some  surgeons 
to  apply  strong  compound  tincture  of  iodin  to  the  entire  surface,  and, 
lastly,  a  10  percent  solution  of  iodoform  and  glycerin,  after  which  the 
wound  should  be  closed  with  deep  sutures  of  catgut  and  superficial 
sutures  of  any  desired  material.  If  doubt  exists  as  to  the  aseptic  condi- 
tion of  the  joint  when  the  operation  has  been  completed,  the  same  should 
be  freely  drained  with  rubber  tubes  or  with  iodoform  gauze  passed 
transversely  through  the  articulation.  The  joint  is  then  covered  with  a 
large  dressing  and  immobilized  by  means  of  splints  or  plaster-of-paris. 

Treatment  of  Tuberculous  Abscess  of  the  Hip-joint. 

English  Method — Cheyne-Treves. — ^After  free  incision  the  abscess 
wall  is  clipped  away,  and  by  means  of  Barker's  flushing  spoon  the  abscess 
cavity  thoroughly  scraped  and  cleared  out.  The  addition  of  flushing 
with  hot  normal  salt  solution  to  the  use  of  a  sharp  spoon  is  a  great  safe- 
guard against  the  risk  of  general  infection  which  accompanies  scraping 
alone.  As  the  material  is  scraped  away  the  rush  of  fluid  through  the  in- 
strument washes  out  the  wound  at  once,  and  thus  prevents  infection  be- 
ing carried  into  the  circulation.  After  the  abscess  has  been  scraped 
out,  an  ounce  or  more  of  10  percent  solution  of  iodoform  and  glycerin 
is  injected  into  the  cavity,  the  wound  closed  without  drainage,  and  anti- 
septic dressings  applied.  The  successful  treatment  depends  upon  strict 
asepsis.  Should  the  wound  become  septic,  good  results  cannot  be  ex- 
pected from  treatment  of  abscess  alone.  Should  sepsis  occur,  serum 
may  collect  and  the  wound  be  distended,  in  which  case,  if  there  be 
fluctuation,  the  wound  must  be  opened  and  the  fluid  evacuated.  EflFort 
should  be  made  to  heal  the  wound  by  granulation. 

Should  a  sequestrum  be  felt  when  the  abscess  is  opened  and  scraped, 


3l6  POSTOPERATIVE    TREATMENT. 

or  should  a  cheesy  deposit  in  the  bone  be  easily  reached,  it  should  be  re- 
moved, but  any. further  attempt  to  clear  out  the  joint  at  this  stage  is  un- 
necessary and  should  be  avoided.  (Cheyne-Burghard,  "Manual  of 
Surgical  Treatment.") 

When  there  are  Septic  Sinuses. — When  septic  sinuses  are 
present,  the  conditions  are  altogether  different,  and  in  most  cases  exci- 
sion is  advisable.  When  the  position  of  the  limb  is  good  and  the  pa- 
tient's general  health  is  satisfactory,  and  when  there  are  only  one  or  two 
sinuses,  an  attempt  may  be  made,  by  proper  fixation  of  the  limb  and  the 
establishment  of  good  drainage,  to  bring  about  a  cure  of  the  disease. 
All  sinuses  should  be  enlarged  and  their  tracks  thoroughly  scraped,  un- 
diluted carbolic  acid  being  applied  to  the  whole  length  of  each  sinus 
before  finishing  the  operation.  When  possible,  if  two  or  more  sinuses  can 
be  made  to  communicate,  a  large  drainage-tube  should  be  passed  through 
from  one  opening  to  the  other,  or  the  incision  should  be  sufficiently  free  to 
include  both,  after  which  a  large  drainage-tube  should  be  introduced, 
reaching  down  to  the  bone. 

After-treatment  of  these  cases  will  consist  of  complete_  fixation  of 
the  joint  and  careful  dressing  of  the  sinuses.  The  best  method  of  fixing 
the  joint  is  to  apply  a  plaster-of-paris  splint,  in  which  suitable  openings 
are  left  for  dressing  the  sinuses;  the  plaster  should  extend  up  over  the 
lower  ribs.  It  should  be  strengthened  both  in  front  and  behind  the  hip, 
either  by  strips  of  metal  incorporated  in  the  bandage  or  by  strands  of  tow 
thoroughly  impregnated  with  plaster.  Below,  it  should  reach  to  the 
upper  part  of  the  calf,  so  as  to  fix  the  knee-joint  as  well  as  the  hip,  and 
it  should  be  applied  with  the  hmb  in  a  position  of  abduction.  When  the 
sinuses  are  situated  so  that  it  is  difficult  to  apply  the  bandage  without 
covering  them,  metal  bars  bent  outward  opposite  the  wound  may  be  in- 
corporated with  the  bandage  so  as  to  provide  a  firm  splint,  and  at  the 
same  time  to  give  sufficient  interruption  in  it  to  allow  access  to  the  wound. 

The  drainage-tubes  should  not  be  removed  for  at  least  a  week,  as 
otherwise  there  may  be  some  difficulty  in  reintroducing  them.  When 
two  sinuses  have  been  made  to  communicate,  and  a  tube  has  been  passed 
from  one  to  the  other,  a  long  loop  of  silk  should  be  inserted  into  each 
end  of  the  tube,  and  then,  when  it  is  desired  to  wash  the  latter,  it  will  be 
easy  to  reintroduce  it,  because  one  end  can  be  pulled  upon  until  a  consid- 
erable amount  of  the  tube  has  been  withdrawn;  this  portion  can  be 
washed  with  a  i :  2000  sublimate  solution,  and,  by  traction  upon  the 
second  loop,  the  other  end  of  tube  can  be  made  to  project,  until  the 


MISCELLANEOUS    OPERATIONS.  317 

whole  tube  has  been  thoroughly  washed,  when  traction  on  the  first  loop 
will  pull  the  tube  into  position  again.  After  cleansing  the  tube  it  is  well 
to  dust  it  with  iodoform  before  it  is  put  back  into  position.  We  do  not 
consider  that  these  tubes  should  be  syringed  out  with  any  antiseptic; 
the  only  result  of  this  is  to  irritate  the  wound  without  doing  any  good. 
After  about  three  weeks  the  tube  may  be  cut  in  two  and  shortened,  so 
that  the  outer  end  of  each  Hes  flush  with  the  skin,  while  the  deeper  one 
goes  to  the  bottom  of  the  cavity.  As  healing  takes  place  from  the  bot- 
tom, the  tubes  will  be  gradually  pushed  out  and  must  be  cut  down. 
When  a  very  large  tube  has  been  used  at  first,  a  somewhat  smaller  one 
may  be  substituted  later. 

When  a  tube  has  been  passed  into  each  of  the  sinuses  they  should 
not  be  disturbed  for  about  a  week.  Each  tube  may  then  be  withdrawn, 
cleaned,  powdered  with  iodoform,  and  replaced.  In  all  cases  the  tubes 
should  be  kept  in  as  long  as  possible,  and,  when  it  is  found  that  the  large 
tube  will  not  pass  to  the  bottom  of  the  sinus,  one  of  smaller  caliber  must 
be  substituted.  It  is  well  to  substitute  a  fresh  tube  every  few  days,  as 
granulation  tissue  grows  through  the  holes  and  blocks  the  lumen.  In 
the  fresh  tube  the  holes  will  be  in  a  different  position,  and  the  difficulty 
is  thus  easily  avoided. 

In  a  certain  number  of  cases,  unfortunately  few,  the  sinuses  heal  and 
the  disease  may  be  cured  when  the  patient  is  under  good  hygienic  con- 
ditions and  carefully  treated ;  but  when  there  are  a  number  of  sinuses 
and  when  sepsis  is  marked,  the  attempt,  as  a  rule,  ends  in  failure,  and  it 
will  be  necessary  to  excise  the  joint.  In  other  cases  in  which  the  disease 
is  evidently  active,  and  it  is  obvious  that  the  patient  cannot  be  placed 
under  good  hygienic  conditions,  it  is  well  to  excise  the  joint  at  once.  Be- 
fore proceeding  to  excision,  the  sinuses  should  be  thoroughly  scraped 
and  sponged  with  pure  carbolic  acid,  so  as  to  render  the  wound  as 
nearly  aseptic  as  possible  before  the  excision  is  performed. 

Use  oe  Carbolic  Acid  in  Tuberculous  Abscess.— Carbolic 
acid  in  dilute  solutions  was  at  one  time  injected  into  tuberculous  cavities, 
but  its  use  has  been  generally  discontinued  because  of  the  danger  of 
poisoning.  Recently  Phelps  has  advocated  the  use  of  pure  carbolic  acid 
in  the  treatment  of  tuberculous  abscesses  and  sinuses.  This  is  injected 
into  the  fistula  or  into  the  abscess  cavity,  which  has  been  opened,  and  is 
allowed  to  remain  for  about  a  minute,  when  it  is  neutralized  by  copious 
injections  of  alcohol,  after  which  the  part  is  thoroughly  cleansed  by  salt 
solution.     Carbolic  acid  doubtless  acts  as  a  caustic,  destroying  the  in- 


3l8  POSTOPERATIVE    TREATMENT. 

fected  granulations  and  stimulating  the  reparative  processes.  Other 
remedies  of  this  class — for  example,  tincture  of  iodin,  zinc  chlorid,  actual 
cautery,  and  the  like — are  also  used,  and  in  certain  cases  with  benefit. 
In  the  treatment  of  tuberculous  ulcerations  ichthyol,  balsam  of  Peru 
dissolved  in  castor  oil  of  a  strength  of  lo  percent,  as  suggested  by  Van 
Arsdale,  is  a  satisfactory  application. 

Venous  Stasis — Bier's  Treatment. — Bier's  treatment  of  tubercu- 
lous joint  disease  was  suggested  by  the  observation  of  Rokitanski,  that 
phthisis  was  uncommon  in  individuals  suffering  from  disease  of  the 
heart  when  the  mechanical  obstruction  was  sufficient  to  cause  venous 
congestion  of  the  lungs. 

Treatment  by  means  of  venous  stasis  is  conducted  as  follows :  A  rub- 
ber bandage  is  placed  about  the  limb  above  the  joint,  under  sufficient 
tension  to  interfere  with  the  return  of  the  venous  blood;  and  in  order 
to  limit  the  congestion  to  the  diseased  part,  the  limb  is  firmly  bandaged 
with  a  flannel  bandage  up  to  the  joint,  from  below.  Between  the  two 
the  tissues  about  the  joint  become  swollen,  the  local  temperature  is  in- 
creased, and  the  color  of  the  skin  becomes  bluish-red.  At  first  the 
congestion  is  continued  for  short  periods  only  during  the  day,  as  it  is 
somewhat  painful.  These  are  lengthened,  until  finally  it  may  be  appHed 
continuously. 

If  the  disease  is  active,  the  treatment  may  hasten  abscess  formation ; 
and  if  sinuses  are  present,  the  discharge  is  usually  increased  for  a  time. 
The  venous  congestion  is  supposed  to  stimulate  the  formation  of  healthy 
granulations  and  their  further  transformation  into  fibrous  tissue;  and 
according  to  the  investigations  of  Hamburger,  the  serum  of  venous  blood 
has  a  distinct  germicidal  property.  The  treatment  may  be  applied 
most  conveniently  at  the  knee-joint  and  ankle-joint,  but  if  applied,  it 
should  serve  merely  as  an  adjunct  to  mechanical  protection. 

lodoform-glycerin  Injections  of  Tuberculous  Joints. — A  lo 
percent  solution  of  iodoform  in  glycerin  has  been  very  much  extolled  in 
the  treatment  of  tuberculous  joints.  Ochsner  lays  down  several  points 
in  the  technic  which  should  be  carefully  obeyed : 

"i.  The  trocar  should  never  be  plunged  directly  into  a  joint,  but  al- 
ways obliquely  underneath  a  fold  of  skin,  so  that  a  valve  will  be  formed 
when  the  trocar  is  withdrawn,  which  will  prevent  infection  of  the  joint- 
cavity  with  pathogenic  microorganisms. 

"  2.  The  amount  of  pressure  employed  in  injecting  the  solution  should 
be  moderate  in  order  to  avoid  rupturing  the  capsule  of  the  joint  and 


MISCELLANEOUS    OPKRATIONS.  319 

forcing  the  fluid,  together  with  tuberculous  contents  of  the  joint,  into 
the  tissues  surrounding. 

"3.  The  amount  of  manijAilation  should  be  limited,  in  order  to  pre- 
vent the  opening  of  lymph-spaces  through  which  secondary  infection 
might  occur. 

"4.  If  the  treatment  does  not  result  in  distinct  benefit  to  the  patient 
after  five  or  six  applications  from  one  to  two  weeks  apart,  it  should  be 
abandoned. 

"  5.  The  patient's  general  and  hygienic  influences  must  be  improved. 

"6.  As  much  as  possible  of  the  fluid  contained  in  the  joint  should 
be  withdrawn  before  the  injection  is  made. 

"7.  Except  in  the  shoulder  and  in  the  sacroiliac  joints,  an  Esmarch 
constrictor  should  be  applied  before  the  joint  is  tapped,  and  left  in  place 
until  a  large  dressing  has  been  fitted  and  held  in  position  by  a  snug 
bandage,  which  will  prevent  hemorrhage  into  the  joint. 

"This  last  precaution  is  not  generally  employed,  but  I  am  confi- 
dent that  it  is  of  distinct  benefit. 

"  In  inserting  the  trocar  into  the  various  joints,  aside  from  carefully 
securing  a  valve  formation  of  the  canal,  the  surgeon  must  avoid  injuring 
important  anatomic  structures  in  the  vicinity  of  the  joint,  and  the  point 
of  the  trocar  must  be  directed  so  that  it  will  not  injure  any  joint  surface. 

"  In  the  smaller  joints  a  very  small  amount  of  the  solution  may  suf- 
fice, the  quantity  employed  depending  upon  the  tension  caused  by  the 
fluid  injected,  which  should  never  be  sufficiently  great  to  endanger  the 
capsule  or  to  produce  severe  pain.  In  the  wrist-joint  the  introduction  of 
the  fine  trocar  used  is  usually  not  followed  by  the  evacuation  of  any  fluid, 
and  here  the  injection  of  2  to  4  c.c.  will  often  be  followed  by  good 
results.  In  the  knee-joint  it  is  often  possible  to  withdraw  several 
ounces  of  fluid,  and  in  cases  it  is  safe  to  inject  as  high  as  30  or  40  c.c. 
of  the  iodoform-glycerin  solution. 

"  In  order  to  prevent  too  great  tension  in  injecting  this  solution  into 
tuberculous  joints,  it  is  well  to  attach  a  soft-rubber  tube  to  the  tro- 
car with  one  end,  and  to  a  glass  syringe  holding  20  c.c.  with  the 
other,  and  then  to  pour  the  solution  into  the  glass  syringe  and  to 
introduce  the  plunger  after  the  rubber  tube  and  the  trocar  have  become 
filled  with  the  solution  spontaneously.  In  forcing  in  the  plunger,  if  the 
pressure  becomes  too  great,  the  intervening  rubber  tube  will  become 
dilated  before  a  sufficient  amount  of  pressure  has  been  exerted  to  injure 
the  capsule  of  the  joint.     In  injecting  the  large  joints  a  large  trocar  is 


320  POSTOPERATIVE    TREATMENT. 

used,  but  in  the  smaller  joints  the  trocar  should  be  just  large  enough  to 
permit  the  transmission  of  the  iodoform."     (Ochsner's  "  Surgery.") 

After-treatment. — Until  the  pain  has  subsided  the  patient  should 
be  kept  at  rest;"  then  a  moderate  amount  of  exercise  is  useful.  The  in- 
jection is  repeated  every  one  to  two  weeks  at  first,  and  less  frequently  later. 

Whitman's  Methods  of  Treatment,*  etc. — Tuberculous  abscess 
is  a  symptom  and  common  accompaniment  of  hip  disease,  which,  in 
cases  treated  under  proper  conditions,  is  not  of  great  importance;  and 
yet,  on  the  other  hand,  it  is  recognized  as  a  dangerous  complication. 
It  is  dangerous  to  life  because  of  the  profuse  suppuration  that  may  follow 
infection,  and  to  function  because  of  the  adhesions  and  contractions  that 
may  result. 

The  Significance  or  Abscess. — If  abscess  appears  early  in  the 
course  of  the  disease,  it  usually  indicates  that  it  is  of  a  destructive  char- 
acter and  that  the  interior  of  the  joint  is  involved,  therefore  perfect 
function  is  less  likely  to  be  preserved  than  in  those  cases  in  which  the 
disease  has  been  confined  to  the  interior  of  the  bone. 

In  certain  instances  abscess  formation  is  preceded  by  an  acute  ex- 
acerbation of  symptoms,  by  pain,  by  an  increase  of  muscular  spasm  and 
consequent  distortion,  and  often  by  an  elevation  of  temperature.  These 
acute  symptoms  subside  and  a  fluctuating  swelling  appears.  It  may  be 
inferred  that  the  pain  in  such  a  case  was  due  to  the  tension  of  the  abscess 
within  the  capsule,  and  that  the  relief  of  pain  followed  perforation  and 
the  escape  of  the  fluid. 

Treatment. — Some  surgeons  have  advocated  absolute  noninter- 
ference with  the  symptomatic  abscess  on  the  ground  that  in  many  in- 
stances it  finally  disappears  by  spontaneous  absorption;  while  in  other 
cases  the  long  delay  allows  the  communication  with  the  joint  to  close,  so 
that  the  danger  of  infection  after  an  opening  has  formed  is  slight.  Fi- 
nally, that  the  results  after  noninterference  are  better  than  those  reported 
after  operative  treatment.  Others  insist  that  all  collections  of  fluid  of 
this  character  should  be  evacuated  when  they  are  discovered,  because 
of  the  danger  of  infection  before  an  opening  forms  and  because  of  the 
advantage  gained  by  preventing  burrowing  of  pus.  There  would  be  little 
to  be  said  against  this  latter  course  were  it  not  that  infection  is  as  com- 
mon after  operative  treatment  as  when  a  spontaneous  opening  forms; 
the  only  advantage  in  favor  of  the  artificial  opening  being  that  the  cavity 
with  which  it  communicates  should  be  smaller  than  when  the  incision  has 

*  "Orthopaedic  Surgery,"  Whitman.    Lea  Brothers  &  Co. 


MISCJOLLANKOUS    OPKKATIONS.  32I 

been  long  delayed;  but  this  is  offset  by  the  fact  that  at  least  20  percent 
of  abscesses  disappear  without  treatment.  In  fact,  as  comjjan-f]  with 
indiscriminate  incisions,  when  j)ro])er  precaution  and  (arc  (annot  be 
assured,  the  let-alone  treatment  should  be  preferred. 

It  would  appear,  however,  that  the  middle  course — between  the  ex- 
tremes— is  the  safest,  and  especially  so  as  by  far  the  larger  number  of 
patients  must  be  treated  under  conditions  which  do  not  admit  oi  proper 
care.  In  the  outdoor  department  of  the  New  York  Hospital  for  Ruptured 
and  Crippled  abscesses  arc  treated  symptomatically.  If  a  swelling  ap- 
pears but  remains  quiescent  and  causes  no  symptoms,  it  is  not  disturbed. 
If  it  enlarges,  the  tension  of  the  fluid  is  relieved  by  aspiration,  which  may 
be  repeated  as  required,  compression,  after  the  evacuation  of  the  fluid, 
being  applied  by  a  pad  and  bandage.  If  the  abscess  is  on  the  point  of 
finding  a  spontaneous  opening,  or  if  its  contents  are  of  such  a  nature  that 
aspiration  is  impossible,  an  incision  is  made  and  the  proper  dressings 
are  applied;  or,  if  the  child  lives  at  a  distance  from  the  hospital,  the 
mother  is  instructed  in  the  manner  of  dressing  and  as  to  the  importance 
of  cleanliness.  If  the  abscess  is  of  large  size,  or  if  acute  symptoms  are 
present,  the  child  is  admitted  to  the  hospital.  Here  the  same  general 
principle  is  followed,  but  at  the  present  time  the  routine  of  treatment  of 
noninfected  abscess  is  free  incision,  that  will  allow  complete  evacuation 
of  its  contents.  The  abscess  membrane  is  removed  by  gently  rubbing 
v/ith  iodoformized  gauze. 

If  the  opening  in  the  capsule  of  the  joint  is  exposed,  this  may  be 
enlarged  to  permit  evacuation  of  the  products  of  disease  within  the 
joint;  the  wound  is  then  closed  with  superficial  and  deep  sutures  and 
a  firm  dressing  applied.  This  operation,  if  performed  under  aseptic 
precautions,  causes  no  disturbance,  and  it  removes  necrotic  material 
which  must  be  an  obstacle  to  spontaneous  absorption.  In  manv 
instances  the  abscess  is  permanently  cured,  although  if  the  condition 
that  induced  the  abscess  remains  unchanged,  fluid  will  again  accumu- 
late, and  if  so  a  spontaneous  opening  will  form  at  the  site  of  the  opera- 
tion. This  operation  is  not  a  radical  cure  of  the  abscess  or  of  the  dis- 
ease; it  is  simply  a  means  of  thorough  evacuation  for  the  puipose  of 
accomplishing  what  the  aspirator  does  only  in  part.  If  the  abscess 
has  become  infected,  its  contents  are  completely  removed;  the  wound 
is  then  packed  with  gauze  and  provision  is  made  for  eflicient  drainage. 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emulsion, 
in  connection  with  the  aspiration,  has  been  thoroughly  tested.     The 


322  POSTOPERATIVE    TREATMENT. 

results,  so  far  as  the  disappearance  of  the  abscess  is  concerned,  are 
not  as  good  as  from  simple  aspiration;  and  as  the  procedure,  being 
somewhat  of  the  nature  of  an  operation,  causes  the  patients  some  dis- 
comfort and  anxiety,  it  has  been  discontinued  in  the  practice  of  the  sur- 
geons here  quoted.  From  the  clinical  standpoint  there  is  little  evi- 
dence that  these  injections  exercise  any  particular  influence  upon  the 
disease,  but  theoretically  iodoform  should  lessen  the  infectiousness 
of  the  tuberculous  fluid,  and  there  appears  to  be  no  serious  objection 
to  its  use. 

The  most  important  element  in  the  postoperative  treatment  of  ab- 
scesses of  the  hip  is  the  prevention  of  contraction  and  subsequent  de- 
formity of  the  limb,  as  well  as  the  correction  of  or  reduction  of  the  de- 
formity in  neglected  or  resistant  cases.  In  nearly  all  large  abscesses 
of  the  hip  more  or  less  structural  changes  and  shortening  of  the  muscles 
and  contracture  of  the  surrounding  tissues  are  necessary  concomitants 
of  the  disease.  Fibrous  tissues  may  form  with  contraction  of  the 
muscles  to  such  an  extent  as  to  destroy  the  functions  of  the  limb.  The 
head  of  the  femur,  or  what  is  left  of  it,  may  be  dislocated,  and  the  limb 
be  fixed  in  such  a  position  as  to  require  forcible  reduction  under  anes- 
thesia, or  osteotomy  may  be  necessary.  It  should  be  remembered 
that  deformity  is  not  actually  the  result  of  a  disease,  but  rather  negli- 
gence on  the  part  of  the  surgeon  who  fails  to  recognize  the  importance 
of  prevention.  After  the  reduction  of  the  deformity,  regardless  of 
the  method  employed,  the  limb  should  be  fixed  in  a  long  spica  bandage 
and  held  in  this  position  by  this  or  other  fixed  appliances  until  the  ten- 
dency to  deformity  has  been  overcome. 

The  Relative  Efficiency  of  Traction  and  Splinting.— Fix- 
ation.^— In  considering  the  vexed  question  of  the  relative  merits 
of  splinting  and  traction  in  preventing  subsequent  deformity,  mus- 
cular spasm,  and  the  consequent  intra-articular  pressure  which  causes 
pain  and  increases  the  destructive  effects  of  the  disease,  these  facts 
must  be  borne  in  mind. 

When  the  patient  is  fixed  in  the  recumbent  posture  it  is  possible 
to  apply  sufficient  traction  upon  the  muscles  to  prevent  the  contrac- 
tion that  causes  injurious  pressure,  and  although  no  amount  of 
traction  will  absolutely  prevent  motion,  yet  with  the  support  that 
the  bed  provides,  practically  speaking,  complete  rest  may  be  assured. 
Only  in  the  exceptional  cases  in  which  the  tension  upon  congested  tis- 
sues about  an  acutely  inflamed  joint  is  intolerable  is  this  method  of 
treatment  inefficient. 


MISCELLANEOUS    OPERATIONS.  323 

The  same  statement  is  true  of  a  properly  applied  spica  bandage  or 
Thomas  brace,  when  the  patient  is  recumbent,  that  it  assures  practical 
rest;  thus  it  prevents  muscular  contraction,  relieves  the  symptoms,  and 
promotes  repair,  although  it  cannot  be  claimed  that  the  surfaces  of 
the  opposing  bones  are  actually  separated  from  one  another. 

But  what  is  true  when  the  patient  is  recumbent  is  not  true  of  am- 
bulatory treatment.  The  traction  exerted  by  the  hip  splint  even  when 
the  limb  is  pendant  is  far  less  effective  than  in  recumbency,  and  when 
it  is  used  as  a  walking  appliance,  for  which  it  was  designed  and  for 
which  it  is  practically  always  employed,  the  traction  is  intermittent 
and  of  doubtful  efficiency.  The  same  loss  in  efficiency  in  less  degree 
occurs  in  all  forms  of  fixative  apparatus  when  used  in  ambulation. 

The  Removal  of  Direct  Pressure.^ — "  Stilting."— Granting 
that  the  traction  brace  as  a  walking  appliance  is  relatively  inefficient 
in  preventing  motion,  and  that  motion  without  friction,  provided  the 
joint  surfaces  are  actually  involved,  is  impossible,  still  it  cannot  be 
denied  that  the  traction  brace  is,  or  may  be,  at  all  times  an  effective 
stilt  in  that  it  protects  the  joint  from  concussion  and  pressure  by  re- 
moving the  foot  from  contact  with  the  ground,  and  prevents  displace- 
ments or  deformity. 

It  is  true  that  the  removal  of  direct  pressure  may  be  attained  by 
the  use  of  axillary  crutches,  but  in  Thomas'  practice  they  were  used 
in  but  few  cases.  In  fact,  it  is  only  by  constant  supervision  that  the 
use  of  crutches  can  be  enforced  upon  children  who  no  longer  suffer  pain, 
and  as  it  is  practically  impossible  to  prevent  the  patient  from  bearing 
weight  upon  the  limb,  stilting  by  this  means  is  relatively  inefficient. 

That  direct  pressure  is  one  of  the  causes  of  upward  displacement 
of  the  femur  may  be  inferred  from  the  statistics  of  Sasse  and  Bruns, 
from  the  surgical  clinics  of  Berlin  and  Tubingen,  where  the  routine 
of  treatment  is  the  plaster  bandage,  without  the  high  shoe  or  crutches. 
In  two-thirds  of  Basse's  and  in  four-fifths  of  Bruns'  cases  there  was 
upward  displacement  of  the  trochanter.  This  is  certainly  a  larger 
proportion  than  would  be  found  in  a  corresponding  number  of  patients 
treated  by  efficient  stilting,  although  statistics  on  tliis  point  from  Ameri- 
can sources  are  lacking. 

In  the  final  comparison  of  the  claims  of  traction  and  fixation  it 
is  of  interest  to  note  that  the  most  enthusiastic  advocate  of  the  Thomas 
treatment  in  this  country  was  trained  in  the  use  of  the  traction  liip 
brace  at  the  New  York  Orthopaedic  and  Dispensar}'  Hospital,  an  in- 


324  POSTOPERATIVE    TREATMENT. 

stitution  founded  by  Taylor  and  in  which  his  methods  have  been  closely 
followed.  Ridlon  states  that  an  experience  in  the  treatment  of  iioo 
cases  by  the  traction  hip  splint  led  him  to  discard  it  in  favor  of  the 
Thomas  brace.' 

The  Practical  Combination  of  Traction  Splinting  and 
Stilting. — Thus  far,  the  methods  of  treatment  by  splinting  and 
traction  have  been  presented  as  if  they  were  necessarily  opposed  to  one 
another  in  principle,  and  as  if  the  theory  were  still  held  that  motion 
without  friction  is  possible;  and  as  if  it  were  believed  that  ankylosis 
is  caused  by  fixation  and  is  prevented  by  the  motion  of  a  diseased  joint. 
At  the  present  time,  however,  it  is  generally  recognized  that  the  prin- 
ciple involved  in  both  methods  is  the  same  and  that  the  actual  merit 


T" 

Fig.  80. — The  Short  Spica  Bandage  in  Combination  with  the  Brace.  One 
Perineal  Band  has  been  Removed  in  Order  to  show  How  the  Joint  is 
Supported  by  the  Bandage. — {Whitman.) 

of  each  must  be  decided  by  practical  experience  rather  than  by  argu- 
ment. The  true  test  of  the  relative  value  of  a  routine  treatment  is 
its  efficacy  in  hospital  practice,  where  its  weak  points  cannot  be  sup- 
plemented by  the  careful  supervision  that  may  make  effective  almost 
any  treatment  that  carries  out  in  some  degree  the  proper  principle. 
This  test  is  all  the  more  necessary  because  the  great  majority  of  cases 
of  this  character  are  to  be  found  among  the  poor. 

A  combination  of  the  Thomas  brace  and  the  traction  hip  splint 
(see  Fig.  80)  is  the  most  effective  mechanical  means  of  relieving  pain 
and  preventing  deformity  that  can  be  employed  in  ambulatory  treat- 
ment. It  has,  however,  the  disadvantage  of  requiring  careful  ad- 
justment, and  it  obliges  the  patient  to  wear  shoulder  straps;  in  other 
words,  much  care  must  be  exercised  to  insure  the  comfortable  adjust- 


MISCELLANi:OUS    OPKKATIONS. 


325 


ment  of  both  appliances.  'I'lius  the  next  step  was  the  combination 
of  the  two,  even  though  the  action  was  somewhat  less  effective.  I'o 
the  pelvic  band  of  the  traction  brace  a  lateral  thoracic  bar  was  attached 
reaching  upward  in  the  axillary  line  to  a  point  ojjposite  the  middle 
of  the  scapula,  where  it  was  joined  to  a  metal  banrl  that  encircled 
the  chest,  like  that  of  the  Phelps 
brace.  When  this  was  securely 
fastened  about  the  chest,  the  bod}' 
and  the  limb  were  held  in  line  by 
a  long  lateral  brace;  the  pelvis  was 
supported  by  the  pelvic  band  and 
the  joint  received  the  additional 
protection  that  was  assured  by  trac- 
tion and  stilting  (Figs.  81  and  82). 

This  brace  and  another  form 
similar  in  principle,  in  which  the 
upright  of  the  thoracic  attachment 
is  fixed  posteriorly  to  the  pelvic 
band,  are  now  in  general  use  at  the 
New  York  Hospital  for  Ruptured 
and  Crippled.  The  efficiency  of 
this  brace  may  be  still  further 
increased  by  replacing  the  perineal 
bands  by  a  metallic  ring.  This 
ring,  which  fits  the  upper  extremity 
of  the  thigh  closely,  is  attached  to 
the  upright  at  an  inclination  cor- 
responding to  the  line  of  the  groin. 

It  is  a  better  support  because 
it  prevents  anteroposterior  motion 
within  the  pelvic  band,  which  the 
perineal  straps  allow.  The  ring  may 
be  used  as  the  only  support   or  it 

may  be  combined  with  a  perineal  band  on  the  opposite  side, 
advantage  if  there  is  a  tendency  toward  adduction. 

The  apparatus  is  most  satisfactory  when  the  hollow  upright  of  the 
Taylor  brace  is  used.  This  is  light  and  strong  and  is  provided  with 
an  arrangement  for  effective  traction,  but  in  hospital  practice  the  up- 
right is  made  of  sohd  metal,  and  the  traction  is  adjusted  by  simple 


Fig.  81.  —  The  Long  Inexpensive 
Brace  with  Solid  Upright  show- 
ing THE  Perineal  Bands  and  the 
Adhesive  Plaster,  as  used  in 
Hospital  Practice. — {Whitman.) 


Tllis  is  of 


320 


POSTOPERATIVE    TREATMENT. 


straps.  The  metallic  ring,  besides  providing  better  fixation,  is  a  firm 
support  that  cannot  be  disturbed  by  the  patient.  It  is,  of  course, 
more  difficult  of  adjustment,  and  it  is  not  suited  to  the  treatment  of 
young  children  because  of  the  difficulty  in  keeping  it  clean  and  dry. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps  (Fig. 
82),  who  has  always  urged  the  advantages  of  fixation  and  traction, 
and  his  brace,  of  which  that  last  described  is  simply  a  slight  modifica- 
tion, is  supplied  with  an  arrangement  for  lateral  traction.  Practically 
speaking,  this  is  a  tape  by  which  the  lower  third  of  the  thigh  is  held 
in  apposition  to  the  upright.  It  hardly  seems  possible  that  appreci- 
able lateral  traction  can  be  exerted  on  the  joint  by  this  means,  and 
certainly  none  whatever  if  the  metallic  ring  is  properly  fitted  to  the 
thigh.  The  simple  straps  do  not  afford  as  effective  traction  as  the 
rack  and  pinion,  nor  is  the  brace,  as  usually  constructed,  sufficiently 


Fig.  82. — The  Long  Hip  Splint  Applied. — {Whitman.) 


strong  to  bear  the  weight  of  the  body  without  bending.  It  should  be 
stated,  however,  that  this  form  of  brace  is  intended  to  be  used  with 
crutches  rather  than  as  a  walking  appliance. 

Many  objections  to  this  attempt  to  combine  the  two  methods  of 
treatment  in  one  appliance  have  been  urged  by  those  who  believe  in 
the  efficiency  of  the  traction  brace.  For  example,  it  is  said  that  the 
splinting  is  ineffective  because  the  movements  of  the  trunk  are  trans- 
mitted to  the  joint,  while  this  is  not  true  of  braces  that  do  not  extend 
above  the  pelvis.  In  reply,  it  may  be  stated  that  the  traction  part  of 
the  combined  splint  remains  as  effective  as  before;  thus  it  follows 
that  this  suggestion  is  an  acknowledgment  of  the  fact  that  the  theory 
of  motion  without  friction  is  no  longer  tenable.  As  a  matter  of  fact, 
however,  it  will  be  found  that  motion  of  the  upper  part  of  the  trunk 
is  absorbed,  as  it  were,  in  the  flexible  lumbar  region  of  the  spine,  before 


I  ISC  K  I.  LAN  ICO  US    OPERATIONS. 


327 


it  reaches  the  joint.     If,  liowever,  such  motion  or  any  molic^n  causes 

discomfort  or  aggravates  the  symptoms,  the  patient  should  Ik;  confincfl 

in  the  recumbent  posture  until  the  acute  phase  of  the  disease  is  passed. 

It  is  said  that  the  brace  is  cuml^ersome,  that  the  patient  cannot 


Fig.  83. — The  Long  Brace  with  Thomas 
Ring  and  Extension  Upright,  Sim- 
ilar TO  Phelps  Brace. — {Whitman.) 


Fig.  84. — Rear  View  of  Brace. — (^ 

man.) 


Whit- 


sit  with  comfort,  and  tliat  it  prevents  normal  acti\'ity.  A  long  brace 
certainly  weighs  more  than  a  short  one,  and  if  a  brace  prevents  flexion 
at  the  hip  and  spine,  it  is  evident  that  the  patient  cannot  sit  with  com- 


328 


POSTOPERATIVE    TREATMENT. 


fort  in  an  ordinary  chair.  As  a  matter  of  fact,  the  patients  themselves 
make  little  complaint  of  the  brace,  even  when  it  has  been  substituted 
for  an  ordinary,  traction  splint;  while  the  greater  restraint  of  activity 
is  a  favorable  element  of  treatment,  since  children  who  do  not  suffer 
pain  are  much  more  likely  to  be  too  active  than  to  be  restrained  by 
any  form  of  appliance.  These  objections  are  trivial,  if  one  is  con- 
vinced that  the  dangerous  and  deforming  disease  that  is  under  treat- 


FiG.  85. — Phelps  Hip  Splint. 


Fig. 


Chair    to   be   Used  with 
Long  Hip  Splint. 


The  patient  sits  upon  the  sound  side,  while  the 
splinted  half  of  the  body  remains  in  the  ex- 
tended position,  the  brace  resting  on  the 
floor. — ( Whitma  n . ) 


ment  may  be  more  easily  controlled  and  that  the  final  result  is  likely 
to  be  better  and  to  be  more  rapidly  attained  by  this  means  than  by 
another. 

This  form  of  brace  is  used  exactly  as  in  the  ordinary  traction  brace. 
If  deformity  be  present,  it  is  reduced  by  one  or  another  of  the  methods 
that  have  been  described.  If  the  disease  be  acute,  recumbency  and 
traction  are  employed  until  this  stage  is  passed.     When  ambulation 


MISCELLANEOUS  OPERATIONS.  329 

is  resumed,  crutches  may  be  employed  for  a  time,  but  during  the  greater 
part  of  the  treatment  the  brace  is  used  as  a  walking  appliance;  as 
accurate  splinting  and  as  effective  traction  being  employed  during 
this  period  as  circumstance  will  permit.  During  the  entire  course  of 
treatment,  supervision  of  the  patient,  with  the  aim  of  adapting  his 
activity  to  the  local  weakness,  should  be  exercised,  even  though  it  may 
be  less  essential  than  when  other  apparatus  is  employed. 


CHAPTER  XV. 

MODERN  TREATMENT  OF   COMPOUND 
FRACTURES. 


CHAPTER  XV. 
MODERN   TREATMENT    OF    COMPOUND    FRACTURES. 

Methods  Advocated  by  Nicholas  Senn. — The  modern  antiseptic 
treatment  must  vary  according  to  the  nature  of  the  wound  and  the 
manner  in  which  it  was  inflicted.  As  a  general  rule,  it  may  be  stated 
that  the  first  dressing  decides  the  fate  of  the  patient,  and  determines 
the  process  of  wound  healing.  The  treatment  of  the  wound  is  of  far 
greater  consequence  than  that  of  the  fracture  itself,  more  especially 
during  the  first  two  weeks.  A  combination  of  most  thorough  anti- 
septic treatment  of  the  former,  immediate  and  perfect  reduction  of 
the  latter,  followed  by  fixation  of  the  fractured  limb  by  some  kind  of 
plastic  splint,  yields  the  best  results.  Whenever  there  is  any  prospect 
of  obtaining  primary  healing  of  the  wound,  the  attempt  should  be  most 
faithfully  made.  In  punctured  and  gunshot  fractures  and  when  the 
wound  is  small  and  clean-cut,  the  surrounding  skin  for  a  distance  of 
several  inches  should  be  shaved  and  thoroughly  disinfected  by  scrub- 
bing with  hot  water  and  potash  soap,  then  with  alcohol,  and  lastly 
with  a  5  percent  carbolic  acid  or  a  i:iooo  mercuric  chlorid  solution. 
If  the  bone  projects  from  the  wound,  the  part  protruding  should  be 
included  in  the  disinfection  before  reduction  is  made,  as  otherwise 
infection  may  be  caused  by  the  reduction.  Such  fractures  must  never 
be  explored,  and  the  wound  should  not  be  enlarged  unless  reduction 
is  impossible  without  so  doing  or  complications  present  themselves 
that  demand  it.  Resection  of  the  projecting  fragment  is  seldom  nec- 
essary, as  reduction  can  usually  be  effected  under  the  influence  of  an 
anesthetic.  It  is  in  cases  of  this  kind  and  in  gunshot  fractures  that,  as 
a  rule,  the  wound  beneath  the  skin  is  aseptic.  Suturing  of  such  w^ounds 
should  be  avoided. 

The  wound,  properly  disinfected,  is  dressed  by  applying  an  anti- 
septic occlusion  dressing.  For  this  purpose  nothing  is  more  eflicient 
than  a  nonirritating  effective  antiseptic  powder,  composed  of  four 
parts  of  boric  acid  to  one  part  of  salicylic  acid,  and  a  compress  of  asep- 
tic absorbent  cotton.  Cotton  is  preferable  to  gauze,  as  it  serves  as  a 
more  efficient  filter,  and  with  the  powder  and  blood  is  soon  converted 


334  POSTOPERATIVE    TREATMENT. 

into  a  dry  crust  that  seals  the  wound  hermetically  and  excludes  it  from 
the  entrance  of  pathogenic  microbes.  About  a  teaspoonful  of  the 
borosalicylic  powder  is  placed  on  the  wound,  and  the  cotton  com- 
press is  applied  and  retained  with  a  gauze  roller,  or,  if  there  is  any 
danger  of  it  becoming  displaced,  it  is  fastened  in  place  with  a  strip 
of  adhesive  plaster  before  the  bandage  is  applied.  The  dressing  should 
not  be  disturbed  until  the  wound  is  healed,  unless  signs  and  symptoms 
indicate  the  existence  of  infection.  Should  infection  follow  this  treat- 
ment, removal  of  the  dressing,  enlargement  of  the  wound,  counter- 
openings,  efficient  tubular  drainage,  energetic  secondary  disinfection, 
and  substitution  of  the  hot  antiseptic  compress  for  the  dry  dressing 
is  the  proper  course  to  pursue.  If  wound  infection  does  not  occur, 
the  compound  fracture  is  practically  converted  at  once  into  a  simple 
subcutaneous  fracture,  and  should  be  treated  as  such. 

P.  Bruns  recommends  for  similar  cases  a  powder  composed  of — 

Carbolic  acid, 25  parts. 

Colophonium, 60      " 

Stearin, 13      " 

Precipitated  carbonate  of  lime, 700      " 

Senn  further  says:  "I  have,  however,  used  the  borosalicylic  pow- 
der, in  the  proportion  specified,  on  an  extensive  scale,  both  in  civil 
and  military  practice,  and  have  been  so  much  gratified  with  the  results 
that  I  can  recommend  it  most  emphatically  as  a  local  application  in 
such  cases,  used  in  the  manner  described. 

"In  LACERATED  AND  CONTUSED  WOUNDS  the  first  and  most  impor- 
tant duty  in  rendering  first  aid  is  to  subject  the  wound  to  an  absolutely 
efficient  and  safe  primary  disinfection.  This  can  be  done  only  by 
first  shaving  and  disinfecting  the  part  of  the  limb  that  is  the  seat  of  the 
fracture,  and,  if  the  fracture  is  near  a  joint,  as  much  of  the  adjacent 
part  of  the  limb  or  trunk  as  will  be  covered  by  the  large  antiseptic 
dressing.  A  common  error  made  in  the  management  of  such  cases  is 
that  the  surface  disinfection  is  not  extended  far  enough.  If  the  wound 
disinfection  cannot  be  made  with  sufficient  thoroughness  without  the 
use  of  an  anesthetic,  it  is  preferable  to  anesthetize  the  patient  rather 
than  neglect  meeting,  to  the  fullest  extent,  the  most  important  indica- 
tions in  the  treatment  of  the  wound.  All  such  wounds  must  be  re- 
garded and  treated  as  infected  wounds.  In  most  instances  the  wound 
is  larger  underneath  the  skin  than  on  the  surface,  and  a  thorough 
primary  disinfection  is  out  of  question  without  enlarging  the  exter- 


MODERN  TRKATMKNT  ()l>     COMPOUND  FRACTURES.        335 

nal  wound  sufficiently  to  expose  every  nook  and  c(jrner  for  the  di- 
rect application  of  the  antiseptic  solution.  After  free  exposure  of  the 
wound  surface  the  surgeon  removes  blood-clots,  foreign  bodies,  and 
loose  fragments  not  required  in  a  satisfactory  process  of  repair.  ]f  on 
hand,  hydrogen  dioxid  should  now  be  poured  into  the  wound;  if  ncA, 
antiseptic  irrigation  with  a  hot  2.5  percent  carbolic  acid  solution  or 
a  solution  of  mercuric  chlorid,  i  :  1000,  should  at  once  be  commenced 
and  continued  until  the  wound  is  surgically  clean.  I  have  more 
faith  in  carbolic  acid  than  in  mercuric  chlorid  as  a  disinfecting  agent 
in  the  treatment  of  accidental  wounds,  as  it  penetrates  the  tissues 
more  deeply  and  leaves  them  in  a  more  favorable  condition  for  the 
healing  of  the  wound  by  primary  intention.  In  extensive  lacerated 
wounds  it  is  advisable  to  cut  away  the  torn  margins,  converting  the 
wound  as  nearly  as  possible  into  an  incised  wound,  better  adapted  for 
successful  suturing.  The  deeper  portions  of  the  wound  can  be  treated 
in  the  same  manner  if  they  are  covered  with  torn  tissue  that  would  be 
in  the  way  of  primary  union,  for  the  purpose  of  preparing  the  surfaces 
for  buried  sutures,  which  can  often  be  employed  to  advantage  in  di- 
minishing the  size  of  the  wound  and  the  space  requiring  drainage. 
The  buried  suture,  of  aseptic  catgut,  is  of  special  value  in  suturing 
vascular  tissue  over  the  detached  fragments  if  the  fracture  is  a  com- 
minuted one.  The  disinfection  must  extend  to  the  seat  of  fracture. 
All  the  loose  fragments  should  be  removed,  disinfected  in  the  carbolic 
acid  solution,  and  immersed  in  a  warm  saline  solution,  ready  for  re- 
implantation after  the  wound  has  been  disinfected. 

"  CouNTEROPENiNGS  FOR  DRA.INAGE  may  bccome  necessary  if  the 
wound  is  irregular,  and  dead  spaces  cannot  be  avoided  by  buried 
sutures.  Tubular  drains  well  fenestrated  must  be  employed  for  this 
purpose.  The  counteropenings  are  made  by  tunneling  the  soft  tissues 
from  the  side  of  the  wound  with  a  pair  of  locked  hemostatic  forceps, 
which  are  pushed  in  the  desired  direction  until  the  skin  over  the  point 
of  the  instrument  is  raised  in  the  form  of  a  cone,  which  is  then  incised 
at  its  base  on  one  side,  and  the  instrument  made  to  emerge  from  the 
wound;  the  drain  is  grasped  and  brought  into  the  wound  with  the  re- 
turn of  the  forceps.  The  tube  should  not  project  further  into  the  wound 
than  the  cavity  it  is  intended  to  drain.  In  large  wounds  multiple 
counteropenings  may  become  necessary.  For  this  special  purpose  the 
drains  should  never  be  thinner  than  the  little  finger,  and  should  not 
be  disturbed  until  the  time  for  infection  to  take  place  has  elapsed — 


336  POSTOPERATIVE    TREATMENT. 

that  is,  for  from  forty-eight  to  seventy-two  hours.  The  wound  itself 
must  never  be  entirely  closed  by  suturing,  as  drainage  is  always  re- 
quired in  such  cases,  and  must  be  maintained  until  all  danger  from 
infection  has  passed.  The  wound  is  drained,  in  preference,  with  a 
single  strip  of  iodoform  gauze,  the  projecting  end  of  which  is  secured 
by  a  large,  aseptic  safety-pin.  Two  ways  present  themselves  for 
dressing  the  wound:  (i)  with  the  dry  dressing;  (2)  with  the  moist 
dressing.  The  surgeon  must  discriminate  carefully  in  making  the 
selection.  The  typical  dry  absorbent  antiseptic  gauze  dressing  is  in- 
dicated in  wounds  that,  from  their  size,  from  the  time  that  has  elapsed 
from  the  receipt  of  the  injury  to  the  first  dressing,  and  from  the  thorough- 
ness with  which  the  primary  disinfection  was  made,  we  have  reason 
to  expect  will  heal  by  primary  intention.  In  applying  such  a  dressing 
a  few  layers  of  iodoform  gauze  should  be  placed  next  to  the  wound, 
the  bulk  of  the  dressing  being  made  of  sterile  gauze,  and  over  and 
around  it  a  thick  cushion  of  absorbent  cotton  should  be  placed.  The 
dressing  should  be  a  copious  one,  and  should  be  retained  in  place  by 
a  gauze  roller.  So  copious  a  dressing  exerts  an  equable  elastic  pressure, 
so  important  an  element  in  securing  muscular  rest  and  in  holding  in 
accurate  and  uninterrupted  contact  the  wound  surfaces.  After  the 
dressing  has  been  applied  and  the  fractured  bone  placed  in  proper 
position,  a  fixation  splint  of  some  kind  should  be  applied  over  the  wound 
dressing.  In  case  no  infection  sets  in,  the  first  dressing  may  remain 
in  place  for  two  or  three  weeks.  Should  the  dressing  become  saturated 
with  blood,  the  surface  may  be  sprinkled  with  borosalicylic  powder, 
and  an  additional  layer  of  cotton  be  applied,  to  make  an  early  change 
of  dressing  unnecessary.  Nothing  is  more  harmful  in  the  treatment 
of  a  compound  fracture  than  meddlesome  surgery ;  the  longer  a  dressing 
can  remain  with  impunity,  the  greater  is  the  probability  of  avoiding 
infection,  and  the  better  are  the  chances  of  obtaining  primary  healing 
of  the  wound." 

The  AFTER-TREATMENT  OF  A  COMPOUND  FRACTURE  by  the  surgeon 
cannot  be  too  carefully  watched.  He  must,  day  after  day,  look  for 
evidences  of  infection.  A  rise  in  temperature  during  the  first  twenty- 
four  hours  usually  means  ferment  intoxication;  after  that  time  it  sug- 
gests septic  infection.  In  fermentation  fever  the  subjective  symptoms 
are  generally  nil;  in  sepsis  they  correspond  in  intensity  with  the  de- 
gree of  intoxication.  The  condition  of  the  tongue  is  of  more  diag- 
nostic importance  than  the  character  and  frequency  of  the  pulse  in 


MODERN  TREATMENT  OE  COMPOUND  IKACTUKES.        337 

discriminating  between  fever  and  sepsis.  In  septicemia  the  tongue 
is  dry  and  usually  brown;  in  fermentation  fever  it  is  moist  and  coated. 
If,  from  the  local  and  general  symptoms,  it  becomes  apparent  that 
the  wound  has  become  infected,  no  time  must  be  lost  in  removing  the 
dressing  and  in  making  additional  provision  for  drainage.  Secondary 
disinfection  is  generally  incomplete  and  unsatisfactory.  If  the  wound 
has  been  sutured,  every  stitch  must  be  removed  and  drainage  established 
wherever  it  appears  necessary.  The  moist  antiseptic  compress  must 
invariably  take  the  place  of  the  dry  dressing,  and  frequent  antiseptic 
flushings  become  indispensable.  It  is  advisable,  under  such  cir- 
cumstances, to  replace  the  more  energetic  antiseptic  solutions,  such 
as  carbolic  acid  and  mercuric  chlorid,  by  Thiersch's  solution  or  a 
saturated  solution  of  the  acetate  of  aluminium,  as  the  former,  used  in 
large  quantities  and  at  short  intervals,  might,  and  often  do,  result  in 
intoxication  that  may  prove  disastrous  and  even  fatal. 

The  ANTISEPTIC  IRRIGATION  should  be  preceded  by  the  injection 
of  hydrogen  dioxid.  If  suppuration  does  not  yield  promptly  to  this 
treatment,  continuous  irrigation  with  either  of  the  mild  antiseptic  solu- 
tions must  be  instituted  at  once,  and  has  often,  in  my  experience, 
been  the  means  of  averting  death  from  sepsis  and  in  preventing  the  ne- 
cessity of  a  secondary  amputation.  Should  this  treatment  not  make 
a  prompt  impression  by  improving  the  local  conditions  and  by  ameho- 
rating  the  general  symptoms,  the  propriety  of  performing  a  secondary 
amputation  must  be  considered,  with  a  view  to  preventing  death  from 
septicopyemia. 

Continuous  irrigation  by  means  of  the  thermal  irrigator  as  de- 
scribed in  Fig.  87  should  be  used,  or  in  the  absence  of  this  apparatus 
a  simple  yet  effective  irrigator  may  be  arranged  in  the  following  manner : 
A  piece  of  rubber  tubing,  six  or  eight  feet  in  length,  can  be  used  as  a 
siphon,  or  may  be  connected  with  an  opening  on  one  side  near  the  bottom 
of  the  reservoir  holding  the  antiseptic  solution,  and  with  one  of  the 
drains  in  the  wound.  A  stop-cock  or  clothes-pin  is  used  to  regulate 
the  size  and  force  of  the  stream.  The  solution  must  be  kept  at  a  tem- 
perature of  blood-heat,  or,  still  better,  a  little  higher,  and  if  more  than 
one  drain  is  employed,  the  point  of  irrigation  is  changed  at  certain 
intervals  from  one  to  the  other.  If  many  drains  have  been  used,  it 
is  advisable  to  connect  them  wdth  several  siphon  tubes  so  as  to  flush 
the  different  parts  of  the  wound  continuously.  By  suspending  the 
limb,  properly  immobilized,  and  placing  underneath  it  a  rubber  sheet, 
23 


33^ 


POSTOPERATIVE    TREATMENT. 


Fig.  87. — Thermal  Irrigator  Stand. 
This  furnishes  means  for  irrigating  with  warm  solutions,  without  the  necessity  of  filling 
the  bottles  with  hot  fluids.  The  outfit  consists  of  two  irrigating  bottles,  mounted 
on  a  strong  upright  frame,  suppHed  with  heavy,  rubber-covered  casters.  The 
bottles  are  adjustable  to  various  heights  as  required.  A  tank  with  lamp  is  provided 
the  former  containing  a  coil  of  sufficient  length  to  allow  fluid  passing  through  it  to 
become  heated  to  the  proper  temperature.  With  a  Volkmann  dropping-tube  for 
continuous  wound  irrigation,  it  makes  an  ideal  irrigator. 


MODERN  TREATMENT  OF  COMPOUND  FRACTURES.       339 

the  fluid  is  drained  into  a  vessel  by  the  side  of  the  bed.  A  compress 
saturated  with  the  same  solution  is  made  to  cover  the  wound  and  is 
to  be  changed  several  times  a  day.  The  general  treatment  in  such 
cases  must  be  stimulating  and  tonic,  su])])ortcd  by  a  concentrated 
and  nutritious  diet.  Should  an  adjacent  joint  become  involved,  free 
drainage  and  continuous  irrigation  constitute  the  proper  local  treat- 
ment. Progressive  phlegmonous  inflammation  calls  for  free  drainage 
and  frequent  or  continuous  irrigation. 

It  is  in  cases  of  this  kind  that  signal  benefit  has  been  derived  from 
applying  a  compress  saturated  with  a  i  :  looo  solution  of  either  the 
lactate  or  the  citrate  of  silver.  If  a  secondary  amputation  becomes 
necessary,  the  operation  must  be  performed  through  healthy  tissue, 
at  a  safe  distance  from  the  infected  territory. 

Comminuted  Compound  Fracture  of  the  Skull. — The  mistake 
is  frequently  made  of  not  removing  a  sufficient  amount  of  the  fractured 
bone.  Spicules  left  even  where  the  periosteum  is  adherent  frequently  in- 
flame and  cause  a  thickness  or  callus  which  may  later  cause  pressure 
at  the  seat  of  the  fracture.  Every  step  of  the  procedure  must  be  done 
under  strict  aseptic  precautions.  Before  the  wound  is  touched  the 
whole  scalp,  or  a  large  portion  at  least,  should  be  carefully  shaved  and 
the  surface  of  the  wound  thoroughly  disinfected.  The  trephine  is 
rarely  needed.  Senn  recommends  that  all  loose  fragments  removed 
should  be  placed  in  a  warm  2.5  percent  solution  of  carbolic  acid  for 
disinfection,  reimplanting  them  carefully  after  the  wound  disinfection 
has  been  completed.  Depressed  fragments  are  elevated  with  the  utmost 
care  to  preserve  their  vascular  connection,  and  if  the  brain  has  been 
exposed  or  injured,  subdural  drainage  is  always  necessary. 

After  the  wound  has  been  rendered  surgically  clean,  if  it  is  thought 
best  to  replace  the  loose  fragments,  they  are  transferred  from  the  car- 
bolized  solution  into  a  warm  solution  of  salt,  prior  to  their  being  placed 
upon  the  surface  of  the  dura.  If  the  fragments  are  large,  Senn  con- 
siders it  advisable  to  fragment  them  with  bone  forceps,  and  reduce 
them  to  the  size  of  the  thumb-nail  or  smaller.  The  fragments  are  then 
conveyed  from  the  salt  solution  to  the  surface  of  the  dura  with  dissect- 
ing forceps,  and  are  planted  in  such  a  manner  that  the  smooth  surface 
comes  in  contact  with  the  dura.  After  placing  them  in  position,  the 
pericranium  and  skin  are  sutured  over  so  as  to  secure  for  the  bone- 
chips  vascular  tissue  on  both  sides.  Drainage  is  established  through 
a  counteropening  in  the  scalp  some  distance  from  the  fracture. 


340 


POSTOPERATIVE    TREATMENT. 


Dry  iodoform  gauze  dressings  are  applied  and  held  in  place  by  a 
roller  bandage.  If  the  wound  remains  aseptic,  the  fragments  will 
recover  their  vitality,  and  the  continuity  of  the  skull  will  be  restored. 
Should  the  wound  become  infected,  all  the  sutures  must  be  removed, 
the  wound  opened  wider,  and  all  the  loose  fragments  removed.  Another 
attempt  may  be  made  to  render  them  aseptic  by  resorting  to  a  vigor- 
ous secondary  disinfection  with  hydrogen  peroxid,  2.5  percent  carbolic 
acid  solution,  or  a  i  percent  solution  of  formalin. 

Open  treatment  and  the  substitution  of  warm  antiseptic  moist 
compresses  in  place  of  dry  dressings  constitute  the  appropriate  after- 
treatment. 

Compound  Fractures  of  the  Leg. — ^After  thorough  disinfection 
of  the  wound  and  limb   and  proper  fixation  of  the  bones,  the  limb 


Fig.  88. — Fracture  Box. — {Brewer.) 

must  be  placed  in  a  suitable  splint  in  order  to  secure  immobilization 
and  prevent  displacement  of  the  fragments,  even  when  attempts  at 
direct  fixation  have  been  made.  Tenotomy  is  often  necessary  and 
frequently  aids  materially  in  the  after-treatment  of  the  more  serious 
cases.  Regarding  this  procedure,  Dennis  writes  as  follows:  "Several 
years  ago  the  author  called  attention  to  tenotomy  in  the  treatment  of 
compound  fractures,  and  in  a  number  of  cases  since  then  he  has  been 
impressed  with  the  value  of  the  operation  in  all  oblique  compound 
fractures,  as  well  as  in  many  simple  fractures.  Tenotomy  relieves 
at  once  any  contraction  of  the  muscles,  permits  the  fragments  to  be 
placed  in  accurate  coaptation,  and  secures  physiologic  rest  to  the  frac- 
ture. It  affords  also  great  comfort  to  the  patient,  and  is  a  valuable 
means  of  fixation  during  the  first  ten  days.  Tenotomy  may  be  em- 
ployed upon  the  tendo  Achillis,  upon  the  hamstring  muscles,  upon 


MODERN  TREATMENT  OF  COMPOUND  FRACTURES. 


341 


the  tendons  of  the  arm  and  forearm,  and  even  upon  the  stcrnomastoid 
muscle  in  fractures  of  the  clavicle." 

The  swelling  following  a  compound  fracture  is  usually  far  more 
extensive  than  after  simple  fractures,  hence  it  is  frequently  a  matter 
of  great  importance  to  adjust  a  splint  or  external  fixation  dressing  that 
will  make  allowance  for  subsequent  swelling,  and  that  need  not  be 
removed  or  disturbed  in  order  to  inspect  or  redress  the  wound.  In 
fractures  of  the  leg  the  author  still  employs  the  "fracture  box  of  our 
fathers"  as  being  the  safest  and  most  comfortable  temporary  splint 
that  can  be  used. 

For  compound  fractures  of  the  thigh  a  modified  Buck's  extension 
apparatus  answers  every  purpose,  and  later,  when  all  acute  symptoms 
have  subsided,  a  plaster-of-paris  splint  (von  Esmarch)  may  be  safely 
applied. 


Fig. 


-Modified  Buck's  Extension  Apparatus. — {Brewer.) 


The  patient  must  be  placed  in  a  narrow  bed  with  a  firm  hard  mat- 
tress. Later,  there  is  frequently  a  tendency  to  e version  of  the  foot. 
This  may  be  corrected  by  pinning  a  strip  of  canton  flannel  along  the 
inner  side  of  the  leg  bandage,  passing  it  under  the  leg  and  over  the 
side-splint,  where  it  is  secured  by  several  tacks.  This  suspends  the 
leg,  taking  pressure  from  the  heel,  and  causes  the  required  inversion 
(Fig.  90). 

Immobilization  of  fracture,  by  means  of  sutures,  wire,  ivory 
pins,  nails,  bone  ferrules,  screws,  etc.,  cannot  be  relied  upon  exclusively. 
A  suitable  external  splint  is  therefore  needed.  In  appl}'ing  any  splint 
or  retention  device,  the  soft  parts  should  be  protected,  especially  near 
and  over  the  seat  of  injury,  and  in  the  neighborhood  of  the  bony  promi- 


342  POSTOPERATIVE    TREATMENT. 

nences,  by  cotton  pads,  or  preferably  sheet-wadding.  Care  should 
be  taken  to  avoid  undue  pressure,  and  a  portion  of  the  limb  below 
the  seat  of  the  injury  should  always  be  left  exposed  to  enable  the  sur- 
geon to  watch  the  condition  of  the  circulation.  In  all  cases  in  which 
extensive  contusions,  edema,  or  ecchymoses  exist,  the  dressings  should 
be  removed  and  the  parts  inspected  frequently  until  all  danger  of 
strangulation,  sloughing,  or  gangrene  has  passed. 

In  all  compound  fractures,  when  the  swelling  and  inflammation 
have  in  a  great  measure  disappeared,  the  limb  should  be  placed  in  a 
more  fixed  or  permanent  dressing.  The  fenestrated  plaster  cast  or  wire 
splint,  allowing  free  access  to  the  wound  and  drainage  openings,  will  be 
found  most  useful  and  hasten  resolution  by  enforcing  rest. 


Fig.  90. — Appliance  to  Overcome  Eversion. — {Brewer.) 

To  apply  an  encircling  plaster  cast  to  a  member,  the  limb  should  be 
held  firmly  in  position  by  assistants.  A  thin  layer  of  lint  or  lintine  should 
first  be  evenly  applied  to  the  part,  after  which  several  layers  of  sheet- 
wadding  should  be  placed  carefully  around  the  Hmb.  This  is  more 
easily  applied  if  made  into  rollers.  After  the  limb  is  evenly  covered  by 
this  material,  several  rollers  of  crinolin  impregnated  with  plaster-of- 
paris  should  be  placed  in  warm  water  to  which  a  teaspoonful  of  salt  has 
been  added.  A  plaster  roller  should  then  be  applied  to  the  limb,  cover- 
ing the  parts  evenly  with  from  four  to  six  layers  of  the  plaster-holding 
material.  Where  a  light  cast  is  desirable,  thin  strips  of  splint-wood 
may  be  inserted  between  the  layers  and  less  plaster  applied.     (Brewer.) 

A  window  should  be  left  or  subsequently  cut  in  the  plaster,  freely 
exposing  the  wounded  area,  which  can  then  be  dressed  without  removing 
the  supporting  cast  (Fig.  91). 


MODERN    TKF.ATMF.NT    Oi'    COMPOUND    I'KAfTCRKS. 


343 


The  cast  is  usually  allowed  to  remain  from  five  to  seven  weeks,  at 
which  time  it  should  be  removed  and  the  limb  carefully  inspected.  If  at 
this  time  the  external  wound  is  entirely  healed  and  the  fracture  shows 
evidence  of  union,  an  ambulatory  splint  may  now  ]je  adjusted,  which 
will  admit  of  greater  freedom  and  be  more  comfortable  to  the  patient. 

Massage  of  the  entire  limb  should  now  be  employed,  and  later 
passive  motion  of  the  knee-joint  and  ankle-joint  should  occasionally  be 
made  until  recovery  is  complete. 

After-care  of  Compound  Fracture  of  the  Arm  at  or  near  the 
Elbow.— The  treatment  of  compound  fracture  of  the  arm  is  practically 
"the  same  as  compound  fracture  occurring  at  any  other  point,  so  far  as 
the  fixation  or  adjustment  of  the  bones  is  concerned,  but  where  injuries 


Fig.  91. — Plaster  Cast  with  Wound  Exposed. — {Stimson.) 

occur  near  the  elbow,  the  reapplying  of  splints  and  apparatus  should  be 
done  sufficiently  often  to  discover  undue  swelling  or  pressure  upon  the 
arm.  All  apparatus  should  be  removed  at  least  once  a  week  and  care- 
fully inspected  during  this  interval.  In  most  instances  it  wall  be  wise  to 
delay  passive  motion  until  firm  union  of  the  bones  takes  place,  seldom 
before  the  sixth  to  the  eighth  week,  and  even  then  must  be  very  gently 
performed.  Massage  to  the  hand,  wrist,  forearm,  elbow,  and  upper  arm 
after  the  external  wound  has  healed  and  the  swelling  has  begun  to 
subside,  is  of  great  value.  The  removal  of  the  sphnt  should  be  tentative 
and  gradual  after  the  union  is  known  to  be  firm.     (Scudder.) 

The  arm  should  be  held  in  a  sling  for  an  hour  and  then  the  splint 
applied.  The  following  day  a  longer  interval  is  granted  without  the 
splint,  and  gradually  the  splint  is  removed  entirely. 

A  snugly  fitting  bandage  will  often  prove  comfortable  as  a  support 
on  first  leaving  off  the  splint.     Passive  motion,  massage,  and  active  use 


344  POSTOPERATIVE    TREATMENT. 

of  the  arm  will  now  assist  in  regaining  the  use  of  the  joint.  At  this  stage 
the  carrying  of  dumb-bells,  pails  or  baskets  filled  with  sand,  and  the 
doing  of  certain  gymnastic  movements  with  the  injured  arm  will  be  of 
material  aid.  All  violent  exercise  of  the  part  is  to  be  avoided.  That 
amount  of  exercise  may  be  allowed  which  leaves  the  arm  moderately 
tired. 

These  patients  should  be  kept  under  observation  for  at  least  four 
months.  It  is  wise  to  treat  such  cases  until  all  that  can  be  achieved 
toward  a  restoration  of  function  has  been  accomplished.     (Scudder.) 

After-treatment  and  Progress  of  Fracture  of  the  Thigh. — In- 
spection of  the  fractured  limb  should  be  made  at  least  daily.  Measure- 
ment should  be  made  twice  a  week  during  the  first  few  weeks,  the  internal 
malleolus  being  reached  through  the  bandage.  Parts  of  the  apparatus 
may  need  changing,  and  straps  may  require  tightening  or  loosening. 
The  heel  and  sacrum  will  require  attention  because  of  the  constant 
pressure  from  lying  in  one  position. 

Ordinarily,  there  will  be  little  or  no  pain  associated  with  the  repair 
of  the  fracture.  After  about  four  weeks  all  apparatus  should  be  removed 
and  the  limb  thoroughly  inspected,  to  detect,  if  possible,  any  uncorrected 
deformity,  and  to  determine  whether  union  is  yet  firm.  In  from  four  to 
six  weeks  repair  in  a  healthy  child  or  young  adult  should  have  been 
advanced  to  the  stage  of  firm  union.  The  apparatus  should  then  be 
reapplied.  At  the  end  of  the  eighth  week  all  apparatus  should  be 
finally  removed.  The  thigh  should  be  washed  and  thoroughly  oiled. 
The  patient  should  be  permitted  to  lie  in  any  position  in  bed  without 
retentive  apparatus  for  one  week.  After  the  splints  are  first  left  off  and 
while  the  patient  is  still  in  bed  daily  systematic  massage  to  the  whole 
limb  should  be  practised,  together  with  slight  passive  and  active  motion 
at  the  knee-joint.  The  patient  should  not  be  allowed  to  bear  weight 
upon  the  unprotected  thigh  until  after  the  ninth  week.  At  the  end  of 
the  ninth  week  he  should  be  allowed  up  and  about  with  crutches,  and 
a  moderately  high-soled  shoe  (two  inches)  should  be  worn  upon  the  foot 
of  the  uninjured  thigh.  He  should  bear  no  weight  upon  the  injured 
leg.-  The  seat  of  the  fracture  should  be  protected  by  coaptation  splints 
and  straps  and  a  light  spica  plaster-of-paris  bandage  from  the  toes  to 
above  the  waist.  At  the  end  of  twelve  weeks  all  support  may  be  dis- 
carded. Of  course,  fractures  of  the  femur  vary  considerably  in  the 
time  the  patient  is  able  to  get  about,  but  the  foregoing  routine  is  that  of 
average  uncomplicated  cases.     Some  surgeons,  however,  would  discard 


MODERN  TREATMENT  OF  COMPOUND  FKAf:T(JKKS. 


345 


all  apparatus  and  get  the  patient  up  and  out  of  bed,  on  crutches,  within 
a  shorter  time  than  here  indicated,  but  if  error  is  committed  it  is  infin- 
itely wiser  to  err  on  the  side  of  safety.  It  is  very  probable  that  massage 
without  any  passive  motion,  as  early  as  the  second  week,  to  the  region  of 
the  knee  and  thigh,  will  prevent  much  of  the  knee-joint  f]is;ibility  and 


/ 

^^J3 

L 

^H'M 

i/ 

^^^^^^^^Ka 

1 

1 

H      1^ 

^H          1 

&„±iSilisBBII^H 

fl^WK'f 

Fig.  92. — Ambulatory  Splint  Applied. 


Fig.  93. — Patient  Walking  with  AiiBULATORY 
Splint. 


muscular  atrophy  that  so  often  hinder  convalescence  in  these  cases. 
It  is  very  important  also,  in  order  to  gain  this  end,  to  see  that  the  exten- 
sion is  made  from  around  and  above  the  condyles  of  the  femur,  and  not, 
as  so  often  happens,  from  the  knee-joint  itself. 


346 


POSTOPERATIVE    TREATMENT. 


In   the   ambulatory   treatment   of   fracture   of   the  thigh  by 

means  of  the  ambulatory  splint  a  high  sole  upon  the  shoe  worn  on  the 
well  foot,  and  crutches,  are  of  very  great  value,  especially  in  children 
and  young  adults.  The  hip  splint,  consisting  of  a  long  outside  upright, 
with  pelvic,  thigh  and  calf  bands,  is  appHed  with  two  perineal  straps 
(see  Figs.  92  and  93).  The  traction  is  made  through  the  windlass 
at  the  foot-piece  after  fastening  the  extension  strips  to  it.  The  counter - 
traction  is  made  by  the  two  perineal  straps.  The  thigh  is  securely  held 
by  coaptation  splints  and  a  bandage  about  the  thigh  and  splint.  The 
patient  goes  about  with  crutches  and  a  high  sole  of  two  inches  upon  the 
shoe  worn  on  the  well  foot,  bearing  a  little  weight 
upon  the  foot  of  the  splint.  As  a  matter  of  fact,  the 
real  value  of  this  method  in  fracture  of  the  thigh 
lies  in  the  improvement  to  the  general  health  by 
the  early  getting  into  the  upright  position  and  out  of 
bed.  This  application  of  the  ambulatory  method 
certainly  is  of  great  comfort  to  the  patient.  That  it 
hastens  the  reparative  process  is  yet  to  be  fully 
demonstrated.  If  the  hip  splint  is  used,  it  should 
be  applied  when  union  is  found  to  be  firm.  After 
wearing  the  splint  in  bed  for  a  few  days  the  patient 
may  get  up  and  about. 

Fracture  of  the  Thigh  in  Childhood  (Scud- 
der). — This  is  usually  caused  by  direct  violence. 
The  fracture  is  often  incomplete.  The  symptoms 
are  those  of  the  same  fracture  in  the  adult.  The 
effusion  into  the  knee-joint  is  seen  perhaps  more 
uniformly  than  in  the  adult.  This  effusion  disap- 
pears from  the  child's  knee-joint  more  quickly  than 
from  the  adult  knee-joint. 

Treatment. — After  reducing  the  fracture, — making  the  incomplete 
fracture  complete  if  perfect  reduction  can  not  be  accomplished  in  any 
other  way, — the  problem  of  maintaining  the  reduction  arises.  In 
children  of  ten  years  and  older  it  is  possible  to  use  Buck's  extension.  A 
plaster-of-paris  spica  splint  from  the  calf  of  the  leg  to  the  axilla  is  also  a 
possible  method  of  immobilization. 

In  children  under  ten  years  of  age  the  Cabot  posterior  wire  frame 
with  coaptation  splints  and  extension  is  the  very  best  method  of  con- 
veniently and  efficiently  treating  a  fractured  thigh  or  fractured  hip. 


F        E 

Fig.  94. — C  A  B  o  T 
WiEE  Splint  tor 
Fracture  of  the 
Hip  and  Thigh. 
— (Scudder.) 


MODERN   TJRKATMENT    OF    COMPOUND    EKACTUKES. 


347 


The  Cabot  posterior  splint  consists  of  two  portions — a  Ixjfly 
part  and  a  leg  part.  The  patient  lies  upon  the  body  part  with  the  thigh 
and  leg  resting  upon  the  leg  part,  as  upon  a  coaptation  splint.  Having 
a  vise  and  simple  iron  wire  the  si/e  of  an  orch'nary  lead-pencil,  this 


Fig.  95. — The  Cabot  Wire  Splint  Ready  for  Use. 
Lateral  view,  showing  curves  of  splint  corresponding  to  small   of  back,  buttock,  and 

knee. — {Scudder.) 


Fig.  96. — The  Cabot  Wire  Splint  Ready  for  Use. 
Front  view,  showing  covering  of  canton  flannel  and  canton-flannel  double  swathe  for 
fixation  to  chest. —  (Scudder.) 

splint  can  be  made  in  a  few  moments;  the  bending  of  the  wire  according 
to  the  diagram  and  fastening  the  free  ends  by  a  strip  of  small-sized  vdve 
being  all  that  is  required.    It  is  necessary  to  make  the  following  measure- 


348 


POSTOPERATIVE    TREATMENT. 


ments  before  bending  the  wire  to  the  general  shape  shown  in  the  diagram 
— namely,  D  E,  the  distance  from  the  axilla  to  the  calf  of  the  leg;  A  D, 
the  width  of  the  trunk;  A  B,  from  the  axilla  to  a  point  midway  between 
the  crest  of  the  ilium  and  the  top  of  the  great  trochanter;  F  E,  the  width 
of  the  leg,  usually  from  two  to  two  and  a  half  inches.  A  D  and  B  C  are 
bent  to  the  curve  of  the  back.  B  C  is  so  bent  that  it  jumps  over  the 
sacrum  and  does  not  touch  posteriorly  excepting  at  B  and  C,  The  long 
rods  are  so  bent  as  to  adapt  them  to  the  posterior  curve  of  the  buttock, 
thigh,  popliteal  space,  and  leg  (see  Figs.  94,  95). 

The  splint  is  covered,  as  in  the  posterior  wire  splint  for  the  leg,  by 
layers  of  sheet-wadding  and  cotton  bandages.  A  swathe  is  attached  to 
the  two  sides  A  B  and'  D  H  of  the  body  part  (see  Fig.  94).  The  child 
is  carefully  laid  upon  this  splint,  the  body  swathes  adjusted,  the  extension 
strips  applied,  traction  made  by  weight  and  pulley  with  the  foot  of  the 
bed  elevated,  coaptation  splints  applied  and  held  in  position  by  straps 


Fig.  97. — Bradford    Bed-frame  for  Fixation  of  Trunk  in  Fracture  of   the 

Thigh. — (Scudder.) 


that  include  the  posterior  wire  splint.  If  it  is  necessary  to  move  the 
child  for  the  making  of  the  bed,  for  the  use  of  the  bed-pan,  or  for 
bathing,  the  extension  may  be  unfastened  temporarily  without  any 
injury  to  the  fracture,  particularly  if  the  coaptation  splints  are  then 
temporarily  tightened  to  secure  a  firmer  hold  on  the  thigh.  The  child 
should  be,  of  course,  clean  from  both  urine  and  feces,  and  the  fracture 
immobilized. 

After  four  weeks  of  bed-treatment  the  child  may  be  up,  with  crutches 
and  a  high  shoe  with  the  Cabot  splint  applied.  Shoulder  straps  should 
be  attached  to  the  splint  when  it  is  worn  in  the  erect  position.  This  is 
one  of  the  simplest,  cleanest,  and  most  efficient  methods  of  treating 
fracture  of  the  thigh  in  young  children.  The -child  can  be  moved  with 
freedom  and  without  pain.  A  light  plaster-of-paris  spica  bandage  may 
be  used  in  convalescence  with  crutches  and  a  high  shoe  on  the  un- 
injured side. 


MODERN  TREATMENT  OE  COMPOUND  ERACTURES.        349 

In  very  small  children  it  is  sometimes  wise  to  use  the  Bradford  (see 
Fig.  97)  frame  and  vertical  suspension  (see  Fig.  98)  of  one  or  both 
thighs.  This  is  an  efficient,  comfortable,  and  clean  method  of  treat- 
ment. The  Bradford  frame  is  an  iron,  frame-like  stretcher,  on  which 
the  child  lies  and  to  which  the  shoulders  and  hips  are  fastened  to  prevent 
the  child's  moving  about.  Counterextension  is  then  secured  by  the 
immobilization  of  the  pelvis  and  hip.  The  extension  is  applied  to  the 
thigh  and  leg  as  usual.  The  limb  is  flexed  on  the  body  to  a  right  angle, 
coaptation  splints  being  applied  to  the  thigh.  After  the  novelty  of  the 
position  passes  away,  the  child  is  perfectly  contented.  As  soon  as 
union  is  firm,  the  permanent  plaster  spica  dressing  may  be  applied. 


Fig.  98. — Fracture  of  Thigh  in  a  Child. 

Bradford  frame.     Vertical  suspension  of  leg  with  weight  and  pulley.     Coaptation  splints 

to  thigh  and  fixation  of  pelvis  by  towel  swathe  about  frame. — (Scudder.) 

and  the  patient  may  be  up  and  about  with  a  high  shoe  on  the  well 
foot  and  with  crutches.  The  use  of  the  long  hip  splint  will  be  of 
great  service  in  these  cases  either  with  or  without  the  extension 
foot-piece  (see  Figs.  92,  93).  After  fracture  of  the  shaft  of  the  femur 
in  children  there  should  be  no  shortening  and  no  especial  difficulty  in 
convalescence.  It  is  wise  to  guard  the  thigh  a  sufficient  time  after 
union  is  firm  to  insure  absolute  solidity  and  freedom  from  bowing  in 
any  direction. 

Complications  during  and  after    repair  of  fractures  form  a 
most  interesting  subject  for  observation  and  study.     The  complete 


35©  POSTOPERATIVE    TREATMENT. 

usefulness  of  a  limb  is  not  fully  restored  as  soon  as  the  fracture  has  been 
repaired.  During  the  process  of  repair,  as  well  as  after  union  is  com- 
plete, it  is  possible  for  many  complications  to  arise  and  require  special 
treatment. 

Surgical  Emphysema  is  a  condition  that  is  often  encountered  in 
the  management  of  fractures.  This  consists  of  the  entrance  of  atmos- 
pheric air  into  the  meshes  of  the  connective  tissue,  and  is  termed 
"surgical  emphysema,"  to  distinguish  it  from  emphysema  of  the  lung. 
The  source  of  the  infiltration  of  the  air  into  the  connective  tissue  may  be 
from  injury  of  the  lung  in  fracture  of  the  rib,  in  which  case  the  emphy- 
sema has  been  observed  to  reach  to  the  scrotum,  and  at  times  it  may 
spread  over  the  face  so  that  the  patient  is  unrecognizable.  The  air  may 
escape  to  such  an  extent  as  seriously  to  embarrass  respiration.  Another 
source  of  emphysema  may  be  from  the  generation  of  gases  as  a  result  of 
putrefactive  changes  or  of  the  growth  of  gas-producing  bacilli  in  the 
tissues.  There  are  only  a  few  cases  observed  of  emphysema  in  simple 
fractures;  the  majority  of  the  cases  have  been  complications  in  com- 
pound fractures.  Or  the  gas  may  escape  from  a  wound  in  the  intestine, 
or  even  from  the  air-sinuses  in  the  bones  of  the  face  and  skull. 

If  the  emphysema  arises  from  injury  to  the  lung,  no  interference  is 
indicated  unless  the  emphysema  is  so  extensive  as  to  produce  dyspnea, 
in  which  case  free  incisions  can  be  made  or  the  air  allowed  to  escape 
through  a  trocar.  The  air  is  usually  absorbed  in  a  few  weeks,  and 
produces  no  harm,  since  it  has  been  filtered  in  its  passage  through  the 
lungs,  and  is  therefore  not  likely  to  set  up  inflammation.  In  case  the 
condition  arises  from  putrefactive  changes,  the  application  of  the  prin- 
ciples of  antiseptic  surgery  is  required. 

Edema  consists  of  the  infiltration  of  serous  fluid  into  the  interstices 
of  the  areolar  tissue,  and,  unless  it  is  due  to  some  organic  disease  of  the 
liver,  kidney,  or  heart,  is  the  result  of  too  tight  bandaging  or  the  sudden 
removal  of  the  splint,  or,  finally,  of  obliteration  of  the  large  veins  from 
thrombosis.  If  due  to  local  causes,  the  edema  usually  disappears  after 
the  removal  of  the  cause,  or,  if  to  a  loss  of  support  of  the  vessels  by  the 
removal  of  the  splint,  the  edema  rapidly  subsides  as  soon  as  the  function 
of  the  limb  is  restored.  Placing  the  limb  under  a  faucet  and  douching 
it  alternately  with  hot  and  cold  water  will  stimulate  the  circulation; 
and  this  treatment,  aided  by  massage  of  the  muscles  when  the  patient 
begins  to  walk,  will  relieve  the  condition. 

Delirium  tremens  and  traumatic  delirium  are  two  complica- 


MODERN    TREATMENT    OF    COMPOUND    JKACTUKES.  35 1 

tions  that  frequently  occur.  The  differential  diagnosis  is  often  difficult 
to  make,  but  the  tremor  in  the  limbs  and  an  alcohoHc  history  occurring 
soon  after  the  receipt  of  injury,  with  absence  of  fever,  point  to  the 
former  as  contrasted  with  the  latter  condition.  In  both  forms  of  de- 
lirium the  patient  has  delusions,  mutters  incoherently,  is  often  violent 
and  excitable,  and  has  a  dry,  tremulous  tongue  accompanied  by  free 
diaphoresis. 

Treatment  consists  in  placing  the  fracture  at  once  in  a  plaster-of- 
paris  splint  or  fixed  dressing,  and  watching  the  patient  carefully,  even 
to  the  extent  of  employing  a  special  attendant.  If  the  delirium  becomes 
too  active  and  it  is  impossible  to  restrain  the  patient,  a  strait-jacket 
must  be  employed.  If  the  patient  is  robust  and  young,  liquor  can  be 
withheld ;  but  if  aged  and  feeble,  it  is  necessary  to  continue  stimulants 
with  judgment.  The  bromids,  chloral,  hyoscyamus,  and  in  some  cases 
morphin,  are  the  remedies  which  have  proved  the  most  successful.  In 
organic  disease  of  the  kidney  morphin  is  apt  to  cause  suppression  of 
urine,  and  must  be  employed  with  caution.  The  diet  must  be  nutritious 
and  abundant,  and  the  patient's  strength  maintained. 

It  should  not  be  forgotten  that  acute  septicemia  with  rapid  rise  of 
temperature  may  cause  delirium  closely  resembling  that  of  trauma. 
Therefore,  in  the  after-treatment  of  compound  fractures,  should  delirium 
later  supervene,  the  wound  must  be  carefully  examined  for  local  signs  of 
infection  and  treated  accordingly. 

Pneumonia  is  a  complication  likely  to  arise  during  the  repair  of  a 
fracture.  It  is  especially  likely  to  occur  in  alcoholic  patients  with  com- 
pound fractures,  and  forms  a  most  serious  complication.  The  treat- 
ment of  the  disease  is  conducted  upon  the  same  principles  that  govern 
the  physician  in  a  case  of  traumatic  pneumonia  (see  page  47). 

Osteomyelitis  is  a  form  of  suppuration  in  bone,  and  is  caused  bv 
the  presence  of  septic  micrococci  in  the  wound.  It  is  therefore  most 
likely  to  occur  in  compound  fractures,  although  the  disease  in  the  form 
of  acute  abscess  may  occur  after  any  traumatism  of  bone.  The  osteo- 
myelitis sets  up  necrosis  of  bone,  and  the  patient  may  die  from  septic 
infection  before  the  sequestrum  can  be  removed.  Septic  emboH  may 
start  from  the  thrombi,  and  metastatic  abscesses  develop.  The  treat- 
ment of  this  condition  consists  in  freely  exposing  the  seat  of  the  abscess 
and  trephining  the  bone  above  it,  if  necessary,  in  order  to  reach  the  dis- 
ease and  establish  free  drainage,  after  w^hich  the  wound  is  treated  as 
heretofore  described  under  "Septic  Wounds." 


352  POSTOPERATIVE    TREATMENT. 

Fat-embolism  was  first  fully  described  by  Wagner  and  Zenker. 
Fat- embolism  means  the  entrance  of  fluid  fat  from  the  medulla  of  the 
bone  into  the  veins  in  the  immediate  vicinity  of  the  fracture,  and  through 
these  channels  into  the  capillaries  of  the  brain,  spinal  cord,  lungs, 
kidneys,  and  other  essential  organs.  The  presence  of  fluid  fat  in  the 
blood  was  described  in  1836  by  R.  W.  Smith,  but  the  clinical  importance 
of  this  condition  was  not  recognized  until  recently  through  the  investiga- 
tions of  von  Bergmann,  Czerny,  and  Scriba.  Dejerine  has  experi- 
mentally produced  fat-embolism  in  the  lower  animals  by  inserting 
laminaria  tents  into  the  medullary  cavity  of  the  bone.  The  symptoms 
of  fat-embolism  appear  on  from  the  third  to  the  fifth  day,  as  a  rule,  and 
resemble  those  of  secondary  shock.  They  occur  before  the  time  at 
which  venous  thrombosis  or  pulmonary  embolism  would  be  expected  to 
appear.  Great  dyspnea,  associated  with  the  Cheyne-Stokes  respiration, 
irregularity  of  the  heart's  action,  and  a  sudden  rise  of  temperature,  to- 
gether with  twitching  of  the  muscles,  as  well  as  paralysis  of  certain 
muscles,  have  been  observed  in  these  cases,  and  also  fat-globules  are 
found  in  the  urine.  There  have  been  no  metastatic  abscesses  discovered 
where  an  autopsy  has  been  made.  This  group  of  symptoms  must  not 
be  mistaken  for  shock  following  fracture  nor  for  pulmonary  embolism. 
Shock  may  be  said  to  be  present  three  hours  after  the  fracture,  fat- 
embolism  three  days  after,  and  pulmonary  embolism  three  weeks  after. 
For  convenience  .these  complications  have  been  arranged  in  the  order  in 
which  they  are  most  likely  to  occur,  and  by  associating  these  conditions, 
which  simulate  each  other,  with  the  time  at  which  they  appear,  no 
mistake  in  diagnosis  is  likely  to  arise. 

The  treatment  of  fat-embolism  consists  in  the  administration  of 
ether  in  the  form  of  some  such  preparation  as  Hoffmann's  anodyne,  or 
even  by  hypodermatic  injection.  In  case  of  great  dyspnea  venesection 
has  been  suggested,  and  also  artificial  respiration.  The  pulmonary 
edema  must  be  relieved  by  cardiac  stimulants  and  by  cupping.  The 
fracture  should  be  kept  perfectly  quiet,  lest  any  movement  of  the  frag- 
ments might  cause  further  absorption  of  the  fat  by  disintegrating  the 
medulla  of  the  bone.  In  case  there  are  great  comminution  of  bone  and 
disintegration  of  the  medulla  amputation  may  be  immediately  indicated 
as  a  life-saving  expedient. 

Gangrene  of  the  limb  may  occur  either  as  a  result  of  mechanical 
or  traumatic  causes  or  from  septic  infection.  Gangrene  arising  from 
mechanical  causes  is  due  to  the  application  of  too  tight  a  splint  or  band- 


MODERN  TREATMENT  OE  COMPOUND  FRACTURES.        353 

age  or  to  the  improper  and  prolonged  use  of  a  tourniquet.  The  gangrene 
resulting  from  traumatic  causes  is  due  to  a  crushing  or  laceration  of 
the  soft  structures  near  the  fracture,  or  else  to  the  rupture  of  the  main 
vessels  by  the  same  agency  which  produced  the  fracture,  or  by  the  sharp 
fragments  of  bone,  or,  finally,  to  pressure  from  hemorrhage  or  from  an 
unreduced  fragment.  The  occurrence  of  gangrene  in  the  treatment 
of  fractures  often  leads  to  suit  for  malpractice.  It  is  therefore  important 
for  the  surgeon  to  define  clearly  the  causes  over  which  he  has  control, 
and  those  which  are  beyond  his  control,  such  as  contusion,  laceration 
of  bloodvessels  or  nerves,  pressure  of  a  fragment  of  bone,  or  the  oblit- 
eration of  the  lumen  of  the  artery  from  thrombosis  due  to  senile  changes 
or  calcification  of  the  artery,  and  the  presence  of  diabetes,  with  which 
gangrene  is  so  often  associated,  especially  after  an  injury. 

The  treatment  must  depend  upon  the  cause,  extent,  and  the  general 
condition  of  the  patient.  In  small,  localized  areas  of  gangrene  measures 
should  be  adopted  to  encourage  the  separation  of  the  slough,  while  in 
gangrene  with  a  line  of  demarcation  forming,  amputation  can  be  re- 
sorted to  when  the  healthy  and  dead  tissues  are  clearly  defined.  In  case 
of  rapidly  spreading  gangrene,  with  symptoms  of  serious  septic  intoxi- 
cation, amputation  high  above  the  gangrene  should  be  immediately 
performed. 

Pyemia  and  septicemia  are  conditions  which  arise  in  the  course 
of  the  repair  of  a  fracture,  and  for  a  full  description  of  these  complica- 
tions the  reader  is  referred  to  the  article  devoted  to  a  consideration  of 
this  subject. 

Thrombosis  is  a  complication  that  under  rare  circumstances  occurs. 
When  a  vein  has  been  wounded  a  clot  forms  which  closes  the  vessel. 
From  this  thrombosis  an  embolus  may  travel  to  the  lung,  w^here  it  may 
occasion  death  by  plugging  the  pulmonary  artery.  This  compKcation 
occurs  without  any  warning,  usually  about  three  weeks  after  the  receipt 
of  the  fracture.  The  patient  expires  suddenly  with  great  dyspnea, 
cyanosis,  feeble  pulse,  and  cardiac  pains.  It  occasionally  happens  that 
small  emboli  may  become  detached,  and  produce  alarming  symptoms 
which  gradually  disappear.  In  all  cases  in  which  there  has  been  oblitera- 
tion of  the  veins,  with  formation  of  thrombi,  it  is  dangerous  to  practise 
massage  early  or  to  disturb  the  seat  of  fracture,  since  an  embolus  might 
be  torn  away  from  the  thrombus  and  set  free  in  the  circulation. 

Atrophy  of  the  limb  following  fracture  is  a  complication  that 
is  likely  to  occur,  especially  when  there  has  been  long-continued  dis- 


354  POSTOPERATIVE    TREATMENT. 

use  of  the  limb,  as  in  fracture  of  the  patella.  The  atrophy  is  most 
marked  in  the  muscles  above  rather  than  in  those  below  the  joint 
nearest  to  the  fracture,  and  it  is  especially  prone  to  appear  in  rheu- 
matic diathesis  and  to  involve  the  extensor  muscles.  The  atrophy 
involves  the  connective  tissue  as  well  as  the  muscles,  and  the  condition 
may  be  dependent  upon  an  injury  to  the  nerves  in  the  limb,  or  pos- 
sibly to  a  prolonged  use  of  continuous  compression.  The  atrophy  is 
susceptible  to  treatment  by  gentle  massage,  hypodermatic  injection 
of  strychnin,  shampooing  of  the  limb,  and  moderate  exercise. 

Paralysis,  of  the  muscles  below  the  seat  of  fracture  may  occur 
as  a  complication  during  the  repair  of  fracture,  as  a  result  either  of 
associated  injury  to  the  nerves  supplying  the  affected  muscles,  or  of 
an  inclusion  of  the  nerves  in  an  exuberant  callus  during  the  process 
of  repair.  In  the  former  case  the  paralysis  is  present  simultaneously 
with  the  occurrence  of  the  fracture,  and  if  the  nerve  is  a  mixed  one 
there  will  be  loss  of  motion  and  sensation.  The  simple  tests  for  mo- 
tion and  sensation  should  be  made  in  examining  every  case  of  fracture, 
since  a  paralysis  which  is  overlooked  at  the  time  of  the  examination 
of  the  fracture  may  be  attributed  subsequently  to  carelessness  on  the 
part  of  the  surgeon.  In  case  paralysis  is  due  to  pressure,  electric 
stimulation  of  the  main  nerve-trunk  above  the  callus  fails  to  excite  the 
muscles  to  which  the  nerve  is  supplied. 

The  treatment  consists  in  extricating,  if  possible,  the  nerve  from 
the  callus  by  means  of  a  surgical  operation,  and  the  application  of  the 
constant  current  to  the  nerve  until  it  has  regained  its  function. 

,  Ankylosis  oe  joints  occurs  as  a  complication  following  frac- 
ture. The  ankylosis  may  be  either  permanent  or  temporary.  The 
permanent  variety  consists  of  an  osseous  ankylosis,  and  the  condition 
is  a  result  of  a  fracture  directly  into  the  joint,  so  that  the  fragments 
within  the  joint  have  become  united.  For  the  removal  of  this  condi- 
tion surgery  can  offer  no  relief  unless  an  aseptic  resection  of  the  joint 
is  performed,  and  this  operation  is  limited  to  joints  like  the  shoulder, 
elbow,  wrist,  and  ankle,  and  possibly  a  few  others.  The  temporary 
ankylosis  is  the  result  of  a  concomitant  injury  which  has  set  up  an 
arthritis,  or  it  may  be  due  to  the  prolonged  use  of  extension  in  the 
trea,tment  of  certain  fractures,  or  it  may  be  the  result  of  hemorrhage 
into  the  joint  which  has  excited  a  synovitis  and  arthritis  with  the  for- 
mation of  intra-articular  bands  of  fibrous  tissue.  In  CoUes'  fracture 
the  fingers  are  often  stiff  from  a  thecal  inflammation,  and  it  is  with 
great  difficulty  that  this  condition  can  be  relieved. 


MODERN  TREATMKNT  OF  COMPOUND  ]•RA(:Tl^^r■;S.        355 

The  treatment  consists  in  massage,  shampooing,  the  use  of  hot 
fomentations  of  bran,  the  alternate  douching  with  hot  and  cold  water, 
and  active  movement.  Jt  should  be  remembered  that  passive  motion 
must  be  begun  early,  but  with  the  utmost  care,  in  case  a  fracture  in- 
vades a  joint  or  is  so  near  that  the  callus  is  likely  to  involve  the  joint. 
In  Colles'  fracture  passive  motion  in  the  fingers  should  start  from  the 
first,  and  at  the  wrist  after  one  week.  In  no  ordinary  case  of  fracture 
should  passive  motion  be  delayed  more  than  two  weeks,  unless  delayed 
union  or  nonunion  is  apparent. 

Necrosis  of  bone  occurs  as  a  complication  during  the  repair  of 
fracture,  and  is  due  to  the  fact  that  the  periosteum  has  been  detached 
from  the  fragment  or  from  the  shaft  of  the  bone.  In  the  former  case 
the  loose  fragment  should  be  removed  at  the  time  of  the  reduction  and 
first  dressing;  in  the  latter  case  the  superficial  scale  of  bone  under- 
goes necrosis,  owing  to  its  diminished  vascular  siJpply.  Generally  a 
sinus  leads  down  to  the  exfoliated  bone.  This  tract  should  be  excised 
and  the  bone  removed,  as  a  long-continued  sinus  discharging  ichorous 
pus  is  a  condition  favorable  to  the  development  of  an  epithelioma. 

The  causes  of  nonunion  in  bones  after  fracture  are  constitutional 
and  local.  Among  the  constitutional  causes,  in  which  the  reparative 
action  is  impaired  or  misdirected,  may  be  mentioned  old  age  and  cer- 
tain constitutional  diseases,  as  fevers,  syphilis,  scur\T,  mahgnant  dis- 
ease of  bone,  and  rickets.  Paralysis  may  also  be  a  cause,  as  is  illus- 
trated by  a  case  of  spinal  injury  with  fracture  of  the  humerus  and  leg 
of  the  same  side,  in  which  the  arm  united,  but  the  leg  failed  to  unite. 

Among  the  local  causes  of  nonunion  may  be  mentioned  the  direc- 
tion of  the  line  of  fracture,  since  oblique  fractures  are  more  frequently 
attended  by  failure  of  union  than  transverse  or  impacted.  iVmong  the 
other  causes  may  be  found  separation  of  the  fragments,  the  interposi- 
tion of  foreign  bodies,  muscle,  tendon,  or  fascia,  between  the  ends  of 
the  broken  bones,  or  suppuration,  profuse  hemorrhage,  the  continued 
use  of  wet  dressings,  and,  finally,  improper  dressings,  in  which  the 
splints  are  either  too  tight  or  too  loose.  The  rupture  of  the  main  nutrient 
artery  at  the  time  of  fracture  may  result  in  nonunion. 

The  treatment  of  nonunion  of  bone  following  fracture  is  to  be  con- 
sidered from  a  constitutional  as  well  as  a  local  point  of  view.  It  is 
the  combination  of  general  and  local  treatment  that  is  most  apt  to 
bring  about  the  desired  object.  In  every  case  a  careful  inquiry  should 
be  made  in  regard  to  certain  so-called  diatheses.     The  treatment  of 


356 


POSTOPERATIVE    TREATMENT. 


this  condition  has  for  its  object  the  correction  of  any  constitutional 
dyscrasia.  A  syphilitic  diathesis  should  be  treated  with  the  full  ad- 
ministration of  antisyphilitic  remedies ;  a  gouty  or  rheumatic  tendency, 
by  remedies  suited  to  these  special  diseases;  scurvy,  rickets,  scrofula, 
tuberculosis,  and  marasmus  should  be  treated  with  tonics  and  a  nu- 
tritious diet,  with  the  aid  of  the  best  hygienic  surroundings.  The 
tonics  best  suited  for  those  conditions  in  which  the  general  health  is 
impaired  are  iron  and  the  phosphates. 

In  conjunction  with  the  general  management  the  local  treatment 
is  to  be  pursued.  The  means  employed  must  consist  of  the  removal 
of  any  offending  body  between  the  fragments  and  the  excitation  of 
a  certain  amount  of  inflammation  around  the  ends  of  the  fragments. 
The  local  treatment  must  further  consist  in  the  application  of  an  im- 
movable splint  specially  adapted  to  the  exigencies  of  the  case. 

The  operations  which  have  been  devised  with  a  view  to  effecting 

union  in  ununited  fracture 
are  multifarious.  They  all 
have  one  common  object — 
viz.,  the  excitation  of  in- 
flammation; but  many  of 
the  old  operations  are  at 
the  present  time  abandoned 
as  a  result  of  the  intro- 
duction of  antiseptic  sur- 
gery. The  use  of  the  seton, 
the  injection  of  irritating  fluids,  the  cauterization  of  the  fragments, 
the  application  of  blisters  and  of  caustic  alkalis  to  the  skin  over  the 
site  of  the  ununited  fracture,  the  introduction  of  electric  currents, 
the  violent  percussion  with  the  mallet^ — are  among  the  various  opera- 
tions which  are  practically  discarded  as  unsuitable,  and  in  their  places 
modern  surgery  has  instituted  a  number  of  aseptic  operations,  for 
description  of  which  the  reader  is  referred  to  works  of  general  surgery. 
Fracture  of  the  Patella. — Fractures  of  the  patella,  whether  simple 
or  compound,  are  usually  accompanied  by  more  or  less  profuse  swell- 
ing, which  makes  its  appearance  ordinarily  within  three  or  four  hours 
following  the  receipt  of  the  injury,  the  swelling  being  due  to  the  accu- 
mulation of  blood  and  synovial  fluid  in  the  knee-joint.  Before  any 
method  is  resorted  to  with  a  view  to  bringing  the  fragments  into  ap- 
position, the  surgeon  must  endeavor  to  control  and  modify  the  joint 


Fig.    99. — H.   H.    Smith's     Splint    for   Un- 
united Fracture  of  Leg. — {Dennis.) 


MODERN  TREATMENT  OF  COMPOUND  FRACTURES.        357 

inflammation.  The  ice-bag  is  used  with  great  benefit  during  the  first 
day  or  two,  after  which  lead-water  and  laudanum  wash  may  be  used. 
So  soon  as  the  inflammation  and  swelling  have  subsided,  uniform  pres- 
sure by  means  of  an  elastic  bandage  will  hasten  absorp^tion  of  the 
fluid.  The  limb  can  be  so  placed  by  slightly  elevating  the  leg  that 
the  position  alone  will  afford  an  excellent  method  of  treatment.  The 
limb  may  be  elevated  and  placed  upon  a  well-padded  Hamilton  splint, 
or  an  ordinary  inclined  plane  sphnt  (see  Fig.   loo),  so  that  the  foot 


Fig.  100. — Inclined  Plane  Splint. — (Dennis.) 

is  from  one  to  two  feet  above  the  foot  of  the  bed,  and  in  this  way  the 
rectus,  crureus,  and  vasti  are  relaxed,  and  there  will  be  no  traction 
upon  the  upper  fragment.  No  operative  measures  should  be  at- 
tempted until  the  inflammatory  action  has  subsided,  unless  the  frac- 
ture is  compound,  when  the  operation  of  fixation  of  fragments  should 
.be  performed. 

There  are  two  methods  of  treating  fracture  of  the  patella — one  is 
called  the  expectant  plan,  and  the  other  the  operative  treatment.  In 
the  expectant  plan  or  method  of  treatment  the  lower  fragment  is  fixed 
by  means  of  adhesive  straps  or  other  appliances  placed  obliquely  about 
the  leg  and  splint,  and  fastened  to  the  splint  above  the  fragment,  either 
a  ham-splint,  an  Agnew  splint,  or  a  Cabot  posterior  wire  splint  hav- 
ing first  been  adjusted  to  the  posterior  surface  of  the  limb. 

Treatment  by  the  Expectant  or  Nonoperative  Method. — 
During  the  first  four  weeks  fixation  of  the  knee,  elastic  compression, 
douching,  massage,  the  thigh  flexed  slightly  on  pelvis,  the  leg  ex- 
tended, retentive  straps,  coaptation  splints,  are  the  measures  em- 
ployed. At  the  fourth  or  sixth  week  remove  all  apparatus,  apply 
removable  splint,  allow  walking  with  crutches,  and  use  daily  passive 
motion.  At  the  eighth  week  discard  crutches,  use  cane,  and  permit 
limited  daily  active  motion.  At  the  sixth  month  discard  splint,  apply 
flannel  bandage,  and  discard  cane.  At  the  eighth  to  the  tenth  month 
remove  all  support.     (Scudder.) 


358 


POSTOPERATIVE    TREATMENT. 


The  OPERATIVE  TREATMENT  consists  in  the  reduction  and  fixation 
of  the  fragments  which  are  held  in  place  by  wire  or  animal  sutures, 
after  which  the  limb,  in  an  extended  position,  is  immobilized  by  some 
fixed  dressing.  ,  If  the  operation  is  performed  with  aseptic  precaution, 
the  drainage  may  be  removed  on  the  second  or  third  day. 

Postoperative  Treatment. — At  the  end  of  about  four  or  six  weeks 
from  the  injury  union  will  be  found.  The  retentive  straps  and  coap- 
tation splints  should  now  be  removed,  and  the  leg  immobihzed  by  a 
plaster-of-paris  splint  extending  from  below  the  calf  of  the  leg  to  the 
groin.  Fixation  (prevention  of  flexion  and  extension)  on  walking  is 
to  be  maintained  for  at  least  six  months  after  the  injury.  Protecting 
the  knee  thus  when  walking  for  this  period  of  six  months  does  not  pre- 
clude active  movements  of  the  knee  when  not  bearing  weight  upon  the 
limb.  At  the  end  of  that  time  the  patient  may  be  allowed  to  go  about 
with  a  cane  and  a  snugly  fitting  roller  bandage.     This  bandage  should 


Fig.   ioi  — Agnew's  Splint  Applied. — {Dennis.) 

be  made  of  medium  weight  flannel,  cut  straight  with  the  weave  and 
not  on  the  bias.  The  bandage  should  be  applied  from  the  middle  of 
the  calf  of  the  leg  to  the  middle  of  the  thigh  when  the  leg  is  completely 
extended.  As  the  patient  becomes  confident  of  his  strength,  the  cane 
need  not  be  carried.  Sudden  movements  are  to  be  avoided.  At  the 
end  of  eight  or  ten  months,  varying  with  the  individual  case,  all  sup- 
port may  be  omitted  from  the  knee. 

The  Restoration  or  the  Function  of  the  Joint. — From  the  day 
of  the  injury  daily  massage  to  the  whole  limb  is  important.  It  main- 
tains the  muscles  in  good  tone.  It  prevents  adhesion  of  the  frag- 
ments to  the  tissues  about  the  condyles  of  the  femur,  a  not  uncommon 
cause  of  ankylosis  of  the  joint.  It  facilitates  the  absorption  of  the  effu- 
sion of  blood  and  synovial  fluid.  After  the  fourth  week  daily  passive 
motion  is  to  be  instituted — at  first  very  slight  indeed,  barely  two  or 
three  degrees.     If  the  relative  position  of  the  fragments  is  not  altered 


MODERN  TREATMENT  OF  COMPOUND  FRACTURES.        359 

I)crceptibly  by  this  passive  motion  and  lasting  jjain  is  absent,  it  may 
be  persisted  with  in  regularly  increasing  amounts.  At  the  expira- 
tion of  eight  or  ten  weeks  active  motion  at  the  knee  joint  may  cau- 
tiously be  allowed.  The  appearance  of  persistent  and  increasing 
tenderness,  sensitiveness,  or  pain,  and  increasing  separation  of  the 
fragments  are  the  indications  to  diminish  or  cease  passive  and  active 
motion. 


CHAPTER  XVI. 
AMPUTATIONS. 


CHAPTER  XVI. 
AMPUTATIONS. 

General  Remarks. — Modern  surgery  seeks  not  only  to  insure 
healing  by  first  intention  in  an  amputation,  as  in  every  other  opera- 
tion, but  also  to  leave  a  functionally  useful  stump.  A  stump,  to  be 
functionally  useful,  must  be  capable  not  only  of  bearing  weight  and 
pressure,  but  also  of  movement.  But  in  satisfying  these  demands 
we  only  fulfil  part  of  our  endeavors.  The  first  essential  for  the  use- 
fulness of  a  stump  is  freedom  from  pain;  the  second  good  nutrition, 
so  as  to  prevent  atrophy  of  the  muscles  and  bone. 

If  in  recent  times  we  have  obtained  more  useful  stumps  than  for- 
merly, we  are  indebted,  in  the  first  place,  to  asepsis.  Smooth  and  pain- 
less cicatrices  can  only  be  got  when  the  wound  heals  accurately  and 
without  infection,  for  it  is  the  thick,  dense  cicatrices  resulting  from 
an  inflammatory  condition  of  the  wound  that  are  painful.  The  worst 
of  all,  however,  are  the  irregular  hypertrophic  inflammatory  scars 
with  overgrowth  of  bone.  For  this  reason,  as  well  as  because  of  the 
dangers  of  infection  and  the  discomforts  of  delayed  union,  we  should 
do  all  in  our  power  to  insure  healing  by  first  intention.     (Kocher.) 

We  shall  not  here  again  consider  the  treatment  of  wounds,  but  we 
may  refer  the  reader  to  the  chapter  on  the  subject  at  the  beginning 
of  the  book.  We  would  again  point  out,  however,  how  important  it  is 
that  clean  incisions  should  be  made  whose  edges  can  be  accurately 
fitted  together.  Numerous  experiments  under  the  direction  of  Tavel 
have  clearly  proved  that  lacerated  and  irregularly  torn  wounds  are 
much  more  prone  to  be  infected  by  a  definite  number  of  organisms 
than  are  those  which  are  cleanly  cut.  Consequently,  as  absolute  free- 
dom from  germs  in  the  wounds  which  we  make  cannot  at  present  be 
attained,  the  chances  are  that  a  clean  and  properly  conducted  ampu- 
tation will  heal  without  reaction,  while  one  in  which  the  technic  is  poor 
will  suppurate.  Thorough  arrest  of  hemorrhage  and  proper  drain- 
age always  help  to  insure  a  good  cicatrix. 

But  even  though  we  avoid  infection  and  escape  a  h}-pertrophic, 

363 


364  POSTOPERATIVE    TREATMENT. 

needlessly  thick,  dense  cicatrix,  every  stump  is  not  a  serviceable  one. 
The  cicatrix  even  of  a  wound  which  has  healed  by  first  intention  will 
remain  sensitive  if  it  is  exposed  to  special  mechanical  injuries,  such 
as  traction,  or  pressure,  conditions  met  in  cicatrices  on  the  trunk  which 
are  injured  by  the  movements  of  the  body  and  the  pressure  of  clothes. 
Pressure  and  traction  are  to.be  avoided,  especially  when  an  artificial 
limb  has  to  be  worn. 

The  cicatrix  is  exposed  to  most  pressure  if  it  lies  between  the  bone 
and  the  artificial  limb  or  any  external  object.  The  muscles  and  ten- 
dons inserted  into  the  cicatrix  exert  most  traction  on  it  if  it  is  fixed 
to  an  immobile  structure,  especially  to  the  bone.  To  avoid  painful 
pressure  the  scar  should,  therefore,  not  lie  under  the  end  of  the  bony 
stump  in  any  case  in  which  it  is  to  be  utilized  to  bear  weight  or  pres- 
sure. The  only  incisions  which  meet  this  indication  are  the  oblique  in- 
cisions and  their  modifications,  as  illustrated  above.  It  is  only  by 
dividing  the  soft  parts  deeper  on  one  side  than  the  other  that  one  can 
get  a  cicatrix  placed  where  no  pressure  can  be  exerted  on  it. 

It  should  be  noted  that  this  applies  not  only  to  the  skin,  but  also 
to  the  deeper  soft  parts,  the  fascia,  muscles,  tendons,  and  periosteum. 
These  layers  must  also  be  divided  obliquely  if  the  scar  is  not  to  lie 
on  the  pressure  surface.  We  grant  that  scars  vary  in  sensitiveness, 
those  of  muscle  being  less  sensitive  than  those  of  skin;  but,  again,  a 
scar  in  periosteum  behaves  quite  differently,  because  of  the  great  sen- 
sitiveness of  this  membrane,  which,  moreover,  is  easily  stimulated  to 
permanent  proliferative  changes  by  mechanical  irritation.  It  has 
already  been  noted  that  the  cicatrices  on  the  ends  of  nerves  (the  most 
sensitive  parts  of  all)  are  best  kept  out  of  the  region  of  the  stump  by 
division  of  the  nerve  higher  up. 

Therefore  the  united  surfaces  of  the  soft  deeper  parts  (including 
the  periosteum)  should  not  be  situated  directly  over  the  end  of  the 
stump.  This  is  a  point  which  up  till  now  has  not  been  specially  at- 
tended to  in  the  periosteo-plastic  method.  But  even  although  the 
operation  be  properly  performed  by  means  of  the  oblique  method, 
there  still  remains  a  possible  source  of  pain  in  the  stump,  dependent 
on  the  shape  of  the  bone.  If  sharp  corners  and  edges  are  allowed  to 
remain,  which  are  driven  into  the  soft  parts  by  the  weight  of  the  body, 
there  will  always  be  a  painful  stump.  Fortunately  this  is  less  likely 
to  occur  if  the  scar  does  not  lie  under  the  bone.  It  has  been  rightly 
pointed  out  that  in  Syme's  amputation  of  the  foot  a  stump  capable 


AMPUTATIONS.  365 

of  bearing  the  weight  of  the  body  is  provided  if  the  malleoli  arc  not 
sawed  off.  This  can  only  be  obtained  if  one  distributes  the  f^ressure 
on  the  less  prominent  bony  parts.  No  one  would  be  able  to  walk 
if  supported  only  on  the  apex  of  the  most  prominent  point,  the  external 
malleolus. 

In  the  face  of  this  fact  it  can  be  easily  understood  why,  by  the  older 
methods,  we  so  often  got  serviceable  stumps  at  the  epiphysis  (as  Hirsch 
has  shown,  but  for  a  different  reason)  and  so  rarely  in  the  shaft  of  a 
bone.  The  epiphysis  can  easily  be  rounded  off,  and  this  should 
always  be  done,  so  that  the  pressure  from  below  may  be  distributed 
equally  over  a  large  surface.  We  maintain  expressly  that  by  this 
means  painless  and  very  useful  stumps  may  be  obtained  in  amputations 
above  the  malleoli  and  through  the  condyles  of  the  femur  without  any 
osteoplastic  operation,  provided  care  be  taken  that  the  soft  parts  cover- 
ing the  stump  are  movable  and  do  not  contain  a  scar. 

In  the  case  of  the  shaft  of  a  bone  it  is  extremely  difficult  to  attain 
this  rounding  off.  We  have  to  do  here  with  a  tube  with  a  hard  ex- 
terior; and  if  we  do  round  it  off,  we  simply  transfer  the  edges  from 
the  outer  surface  of  the  bone  to  the  medullary  surface.  But  the  main 
point  is  that'  a  really  well-rounded  stump  in  the  shaft  is  technically 
very  difficult  to  get.  We  have  not  yet  got  sufficient  evidence  as  to 
how  far  a  carefully  rounded  section  through  the  shaft,  which  is  covered 
with  scarless  periosteum  and  scarless  soft  parts,  is  really  adapted  to 
bear  weight  without  giving  pain. 

Hirsch  must  be  recognized  as  having  called  attention  to  the  fact 
that  stumps  which  have  been  stripped  of  periosteum  are  quite  useful. 
In  his  method,  as  in  the  most  ancient  methods,  Hirsch  does  not  pre- 
serve the  periosteum.  He  makes  no  osteoplastic  nor  even  a  periosteo- 
plastic  covering,  but  leaves  the  end  of  the  bone  bare  of  periosteum, 
and  it  is  interesting  to  learn  that  at  the  Surgical  Congress  in  Berlin, 
1 90 1,  his  method  found  eloquent  supporters.  Bunge,  from  Eiselberg's 
clinic,  declares  that  it  is  injurious  to  cover  the  stump  with  the  sensi- 
tive periosteum,  and  that,  on  the  contrary,  it  should  be  removed,  as 
the  stump  will  then  be  much  more  useful,  because  less  sensitive.  On 
the  same  grounds  Bunge  scrapes  out  the  medulla,  so  that  this  sen- 
sitive part  may  not  be  pressed  upon. 

Bier  is  convinced  that  it  is  harmful  to  operate  subperiosteall}',  be- 
cause of  the  resulting  overgrowth  of  bone.  But  as  he  prefers  the 
osteoplastic  to  the  older  methods,  it  follows  that  it  does  not  signify 


366  POSTOPERATIVE    TREATMENT. 

much  whether  the  periosteum  is  removed,  or  whether  it  is  replaced 
over  the  sawed  surface.  The  point  is  that  a  good  stump  may  be  formed 
in  various  ways,  provided  the  end  of  the  bone  is  rounded,  broad,  and 
smooth,  and  has  no  corners  or  edges  to  exert  pressure  on  sensitive 
parts.  But  another  point  which  has  been  too  long  neglected  is  that 
it  is  essential  that  the  stump  should  retain  the  good  shape  given  to  it 
at  the  operation. 

For  if  one  wishes  to  prevent  injurious  growth  from  the  medulla 
or  from  the  bone  itself,  the  stump  must  be  subjected  as  early  as  pos- 
sible in  the  functional  relationships  to  which  it  will  later  be  exposed. 
The  irregular  overgrowths  which  are  sometimes  described  will  then 
not  occur,  because  functional  activity  determines  the  direction  of 
cicatrization. 

If  the  wound  heals  rapidly  by  first  intention,  strong  and  serviceable 
stumps  can  be  assured,  be  they  aperiosteal,  subperiosteal,  or  osteoplastic, 
by  taking  care  that  the  skin-cicatrix,  the  fascial  scar,  the  stump  of  the 
nerves,  and  the  muscle-cicatrix  are  away  from  the  seat  of  pressure. 
This  can  be  effected  by  the  oblique  oval  method  of  incision,  by  mak- 
ing the  end  of  the  bone  broad  and  round,  by  causing  it  to  press  against 
portions  of  muscle  and  skin  which  are  only  slightly  sensitive,  and  by 
accustoming  it  early  and  carefully  to  gradually  increased  pressure. 
The  best  stumps  are  always  those  in  which  the  skin  and  periosteum 
covering  the  face  of  the  bone  retain  their  normal  relationship  to  each 
other,  as  in  Bier's  or  Pirogoff's  osteoplastic  operation,  especially  if 
the  skin  is  already  accustomed  to  pressure,  as  in  Gritti's  operation 
and  Kuster's  modification  of  Pirogoff's  amputation. 

Besides  the  necessity  of  preventing  pressure  on  the  scar,  we  must 
direct  attention  to  the  necessity  of  preserving  the  scar  from  traction. 
The  scar  is  pulled  on  by  the  movements  of  a  stump  only  if  it  cannot 
follow  those  movements,  and  this  especially  happens  if  it  is  adherent 
to  the  firm  resisting  bone. 

If,  therefore,  in  addition  to  the  normally  adherent  periosteum,  the 
normally  movable  soft  parts,  especially  the  sensitive  skin,  become 
adherent  to  the  sawed  surface  of  the  bone,  pain  will  naturally  occur 
on  movement.  But  if  one  covers  the  sawed  surface  with  periosteum, 
retaining  its  normal  relation  to  the  soft  parts,  adhesion  of  the  latter 
in  the  course  of  cicatrization  is  prevented.  As  already  seen,  this  ad- 
hesion happens  only  when  one  has  separated  the  soft  parts  from  their 
normal  relation  to  the  flap  of  periosteum.     In  this  lies  the  chief  value 


AMPIJTATRJNS.  367 

of  the  periosteo-plastic  mclhofl,  and  to  a  considerable  extent  oi  the 
osteoplastic  method.  The  latter  is  preferable  to  the  former  in  all 
cases  in  which  the  shaft  is  divided,  because  it  makes  it  easier  to  obtain 
a  rounded-off  stump.  The  layer  of  bone  which  is  applied  to  the  sawed 
shaft  does  not  require  always  to  have  a  very  regular  surface  as  long 
as  it  has  no  sharp  corners  or  edges. 

Bier  has  called  attention  to  the  necessity  of  accustoming  a  stump 
to  pressure  early,  and  using  it  soon,  so  as  to  prevent  atrophy  of  the 
bone  and  soft  parts.  Atrophic  stumps  are  sensitive,  just  as  are  atrophic 
limbs  on  which  no  operation  has  been  performed.  But  it  is  of  equal 
importance  that  the  growth  of  the  end  of  the  bone  should  be  prevented 
from  forming  projecting  angles,  and  thus  interfering  with  the  func- 
tions of  the  stump.  It  is  because  there  is  so  little  danger  of  exostoses 
and  hyperostoses  forming  on  the  end  of  a  bone  when  the  amputation 
has  been  done  by  Hirsch's  aperiosteal  method  that  the  stumps  are  so 
efficient  in  bearing  weight.  Bier's  requirement,  therefore,  applies  espe- 
cially to  periosteo-plastic  stumps,  but  also  to  all  stumps  in  which  pri- 
mary union  gives  opportunity  for  early  use. 

The  principle  of  preventing  hypertrophy  of  scars,  pressure  and 
traction  on  a  scar,  and  atrophy  of  the  soft  parts,  allows  us  to  formu- 
late the  following: 

Procedure  for  a  normal  operation :  An  oblique  incision  (com- 
bined, if  necessary,  with  a  longitudinal  one  in  the  form  of  a  racket 
or  lanceolate  incision,  E,  F,  G,  Fig.  102)  through  skin  and  fascia. 
After  retracting  the  elastic  skin  the  muscles  are  divided  obliquely 
down  to  the  bone.  The  periosteum  is  also  to  be  divided  obliquely. 
The  periosteum  is  then  separated,  along  with  the  superficial  layer  of 
the  cortex  of  the  bone,  by  means  of  a  sharp  raspatory  or  chisel,  or, 
when  possible,  a  flap  of  bone  having  a  movable  periosteal  hinge  is 
made  by  means  of  the  saw ;  lastly,  if  only  a  thin  shell  of  the  cortex  has 
been  raised  up  along  with  the  periosteum,  the  end  of  the  bone  is  simply 
rounded  off,  while  if  a  distant  flap  of  bone  (osteoplastic  method)  has 
been  sawTd  up,  the  end  of  the  bone  must  be  sawed  in  a  curved  direc- 
tion so  as  to  fit  it.  The  periosteal  or  bony  flap  is  sutured  over  the  sawed 
surface  of  the  bone  to  its  periosteum.  The  stumps  of  the  muscles  or 
tendons  are  sutured  to  each  other  or  to  the  surface  of  the  bone  at  a 
distance  from  the  sawed  surface.  Lastly,  the  skin  and  fascia  are  su- 
tured. But  in  cases  in  which  a  periosteal  flap,  or  a  flap  of  bone  and 
periosteum,  cannot  be  obtained  in  normal  relation  to  the  other  soft 


?68 


POSTOPERATIVE    TREATMENT. 


Fig.  102. — Illustrates  Various  Methods  of  Amputation. 

A,  Circular  amputation  of  thigh;  a,  saw  line;  B,  amputation  by  equal  flaps;  b,  saw  line; 
D,  posterior  incision  for  disarticulation  of  hip;  C,  racket  incision;  E  F  and  F  G, 
racket  incision  of  flap  with  circular  method  for  muscles  and  bones;  H,  amputation 
.     of  hip,  equal  flap  method;  K,  Stephen  Smith  amputation  at  knee. 


AMPUTATIONS.  369 

parts,  it  is  better  to  remove  the  periosteum  entirely  from  the  end  of 
the  stump,  to  scrape  out  the  medullary  cavity  (according  to  I-Ciselberg 
and  Bunge),  and  to  round  off  the  edges  of  the  bone  as  dentists  do. 

American  surgeons,  as  a  rule,  now  pay  very  little  attention  to  the 
hard  and  fixed  lines  formerly  laid  down  by  surgical  guidance  in  am- 
putations. The  particular  method  of  amputation  adopted  for  any 
given  case  now  depends  not  upon  the  surgeon's  predilection  for  any 
one  form  of  incision  or  kind  of  flap,  but  upon  the  actual  condition  of 
the  parts;  thus  in  railroad  injuries  or  amputations  following  injuries 
the  main  idea  in  the  surgeon's  mind  is  how  to  insure  the  best  stump 
that  shall  be  as  useful  as  possible.  Not  only  will  he  save  all  that  is 
possible  of  the  limb,  but  will  often  shape  his  flaps  in  an  irregular  man- 
ner so  as  to  obtain  a  longer  and  more  useful  stump.  By  the  proper 
employment  of  antiseptics,  inflammation  and  sloughing  of  the  stump 
have  been  greatly  diminished,  while  the  danger  of  secondar}^  hemor- 
rhage has  practically  disappeared.  It  is  now  possible  to  fashion  flaps 
from  tissues  that  have  been  bruised  by  injury  if  their  vitality  has  not 
been  markedly  interfered  with,  which  heretofore  it  was  not  thought 
possible  to  save. 

Another  noticeable  feature  in  present-day  methods  is  the  increas- 
ingly frequent  use  of  skin-flaps  and  the  diminution  in  the  amount  of 
muscle  employed  to  cover  the  bone.     (Cheyne-Burghard.) 

While  it  is  well  to  be  intimately  acquainted  with  all  the  typical 
methods  of  amputation  suitable  for  different  situations,  it  is  of  extreme 
practical  importance  for  the  surgeon  to  remember  that  he  can  modify 
any  of  these  to  meet  the  varying  circumstances  of  any  individual  case, 
and  that  he  may  use  lateral,  oblique,  or  irregular  flaps  according  to 
the  nature  of  the  case  with  which  he  is  dealing,  so  long  as  he  is  thereby 
enabled  to  provide  a  satisfactory  stump  without  sacrificing  more  of 
the  limb  than  is  absolutely  necessary.  While  no  doubt  the  set  oper- 
ations may  be  followed  to  advantage  in  aseptic  cases  or  for  diseased 
conditions,  the  patient's  interests  are  better  served  in  the  majority 
of  cases  in  which  the  surgeon  is  nowadays  called  upon  to  amputate,  by 
some  irregular  form  of  amputation  than  by  one  on  old-fashioned  lines 
(Fig.  103). 

There  are  two  methods  employed  which  affect  materially  the  after- 
care or  postoperative  treatment,  namely,  the  closed  and  open  methods, 
the  former  being  applicable  to  all  aseptic  cases,  the  latter,  chiefly  to 
railroad  injuries  or  septic  cases. 

25 


370 


POSTOPERATIVE    TREATMENT. 


Fig. 


[03. 


A,  Amputation  of  thigh,  long  anterior  and  short  posterior  flap;  H,  anterior  incision  for 
disarticulation  of  hip,  anterior  and  posterior  flap;  B,  disarticulation  of  knee,  elliptic 
incision  (Bauden's  operation);  C  D,  Lee's  amputation  of  the  leg;  T  T,  Teale's 
amputation  of  leg;  P,  Guyon's  supramalleolar  amputation. 


AMPUTATIONS.  37 1 

All  cases  require  the  ordinary  aseptic  precautions,  such  as  shaving, 
scrubbing  thoroughly,  and  disinfection  of  the  field  of  operation.  The 
entire  limb  except  the  field  of  operation  should  be  carefully  wrapped 
in  disinfected  towels  which  should  be  fixed  in  position  by  safety-pins 
or  a  roller  bandage.  After  the  arteries  have  been  ligated  with  double 
catgut  ligatures,  and  all  hemorrhage  or  oozing  checked,  preferably 
by  hot  normal  salt  irrigation,  after  the  insertion  of  a  small  drainage- 
tube  at  the  most  dependent  portion,  the  muscles  may  be  brought  in 
apposition  by  means  of  catgut  sutures  and  the  skin-flaps  closed  with 
silkworm-gut  and  fine  horsehair  sutures. 


Fig.  104. — -Author's  Method  of  Dressing  after  Amputation. 
Illustrates  manner  of  applying  fixed  bandage  over  the  rubber  tissue  or  jaconet.     The 
rubber  tissue  is  then  folded  back,  exposing  the  stump,  and  protects  the  fixed  ban- 
dages.    The  exposed  stump  is  then  ready  for  the  dressing  and  a  second  bandage  is 
applied. 

Dressings. — The  ordinary  iodoform,  xeroform,  or  cyanid  gauze 
dressings  may  now  be  applied.  Care  should  be  taken  to  have  a  suffi- 
ciently large  amount  to  cover  the  parts  thoroughly.  Over  this  is  placed 
a  layer  of  sterile  absorbent  cotton,  and,  lastly,  plain  sterile  gauze,  over 
which  a  careful  bandage  should  be  applied  with  some  degree  of  firm- 
ness to  obviate  the  spasmodic  jerking  of  the  muscles  of  the  stump. 


372  POSTOPERATIVE    TREATMENT. 

This  latter  is  also  obviated,  with  much  comfort  to  the  patient,  by  ap- 
plying a  splint  to  the  remaining  portion  of  the  amputated  limb. 

After  aseptic  amputations  it  is  our  custom  to  make  the  first  change 
of  dressing  the  sixth  or  eighth  day  following  the  operation,  when  the 
drainage-tubes  may  be  withdrawn.  The  wound  should  be  again 
dressed  as  before  with  several  layers  of  gauze,  cotton,  etc.,  and  remiain 
undisturbed  for  six  to  eight  days.  By  the  end  of  this  time,  or  the  four- 
teenth day,  the  silkworm-gut  sutures  may  be  removed,  and  if  there 
is  no  evidence  of  infection,  narrow  strips  of  sterile  adhesive  straps 


Fig.  105. — Shows  the  Rubber  Tissue  Folded   Back  over  the  Fixed  Bandage, 

Ready  for  the  Dressings. 
The  fixed  bandage  not  only  affords  a  good  hand-hold,  but  prevents  relaxation  of  the 

muscles  and  enables  the  temporary  dressings  to  be  removed  with  little  disturbance 

or  pain  to  the  patient. 

may  now  be  applied  with  sufficient  firmness  to  mold  or  give  the  proper 
shape  to  the  stump.  Over  these  may  be  placed  layers  of  antiseptic 
dressings,  and  a  snug  bandage  applied. 

In  the  second  class  of  amputations,  in  which  more  or  less  sepsis  is 
unavoidable,  after  all  oozing  has  been  controlled  one  or  two  stitches 
of  silkworm-gut  may  be  taken  at  either  angle  of  the  wound,  the  center 
of  the  wound  being  left  open.     It  is  now  carefully  but  gently  packed 


AMPUTATIONS.  373 

with  iodoform  gauze  down  to  and  well  covering  the  end  of  the  bone. 
If  it  be  a  leg  or  thigh  amputation,  it  is  our  custom  before  applying 
the  dressings  to  cover  the  limb  with  sterilized  guttapercha  tissue  (see 
Fig.  T04),  leaving  it  extended  over  the  wound  five  or  six  inches  (see 
Fig.  105).  We  then  apply  our  permanent  bandage,  commencing  four 
or  five  inches  from  the  line  of  amputation,  placing  the  bandage  well 
back  over  the  limb  as  high  up  as  necessary,  and  securing  this  with 
safety-pins.  The  guttapercha  extending  over  the  amputated  part  is 
now  folded  back  over  the  permanent  bandage.  We  now  apply  several 
layers  of  iodoform  gauze  over  and  around  the  open  stump.  Over 
this  are  placed  absorbent  cotton  and  sterile  gauze,  and,  lastly,  a  bandage 
is  placed  as  snugly  as  possible  over  the  dressings  and  extended  back 
over  the  other  or  primary  bandage.  The  primary  or  supporting  ban- 
dage holds  the  tissues  snugly  together  and  furnishes  a  hand-hold  and 
enables  the  other  dressings  to  be  removed  with  less  annoyance  and 
pain  to  the  patient. 

After-treatment  of  Septic  Cases.- — ^The  dressings  should  be  changed 
on  the  day  following  the  operation,  as  there  is  usually  a  considerable 
amount  of  oozing  during  the  first  twenty-four  hours.  The  frequency 
with  which  the  dressings  require  changing  subsequently  will  depend 
upon  the  amount  of  discharge.  No  attempt  should  be  made  to  remove 
the  gauze  drainage  from  the  wound  before  the  fourth  to  the  sixth  day, 
and  only  such  as  becomes  loosened  should  be  removed.  From  the 
sixth  to  the  eighth  day  the  entire  gauze  drain  will  become  loosened 
and  should  be  removed,  the  wound  being  again  gently  packed. 

Healing  of  the  wound  is  usually  rapid,  so  that  by  the  eighth  to  the 
fourteenth  day  the  wound  may  be  drawn  together  by  means  of  sterile 
adhesive  straps.  The  straps  are  applied  with  the  object  of  shaping 
or  molding  the  stump  and  to  guard  against  too  wide  separation  of  the 
flaps.  If  the  suppuration  has  been  excessive,  irrigation  with  Thiersch's 
solution  may  be  necessary,  but  ordinarily  it  is  best  to  avoid  any  form 
of  irrigation  or  moisture,  the  wound  being  kept  clean  by  ■v^dping  it 
carefully  with  gauze  sponges  dipped  in  hot  normal  salt  solution,  and 
after  drying  the  stump  as  carefully  as  possible,  a  dusting-powder  of 
zinc  stearate  may  be  used  and  w^ill  greatly  facilitate  healing. 

Amputation  of  the  thigh  or  leg  by  the  closed  method  requires  four- 
teen to  twenty-one  days  to  heal.  When  the  open  method  is  employed, 
three  to  six  weeks  are  usually  required  before  patients  can  be  dis- 
charged. 


374  POSTOPERATIVE    TREATMENT. 

Faulty  Stumps. — Postoperative  Complications. — A  stump  may 
be  faulty  from  either  of  three  conditions:  namely,  (i)  adhesions  of  the 
cicatrix  to  the  end  of  the  bone,  (2)  involvement  of  sensitive  nerves  in 
the  scar  tissue,  or  (3)  from  a  formation  of  what  is  called  conical  stumps. 

Should  the  scar  become  adherent  to  the  bone,  there  is  often  great 
pain  on  pressure.  This  may  occur  even  though  the  larger  nerves  have 
been  cut  short,  and  is  then  due  to  the  implication  in  the  cicatrix  of  the 
smaller  nerve  branches  which  may  become  bulbous  and  give  rise  to 
excessive  pain.     (Cheyne.) 

Quite  apart  from  the  neurotic  condition  of  the  stump  in  which  the 
cicatrix  is  adherent,  there  is  usually  persistent  and  often  spreading 
ulceration  in  the  scar,  owing  to  the  low  vitality  of  the  cicatricial  tissue, 
which  later  breaks  down  upon  the  slightest  pressure.  This  may  leave 
a  granulating  surface  very  difficult  to  heal.  In  stumps  of  this  kind 
the  nutrition  of  the  entire  end  of  the  stump  is  defective.  It  is  cold, 
livid  in  color,  and  is  very  liable  to  be  affected  by  low  forms  of  inflam- 
mation and  obstinate  ulceration,  or  the  faulty  nutrition  may  give  rise 
to  eczema,  in  which  case  there  will  be  a  sticky,  watery  discharge. 
These  cases  are  frequently  very  obstinate  and  in  the  end  may  call 
for  a  reamputation. 

Treatment. — In  all  cases  of  adherent  cicatrix  much  time  and  use- 
less suffering  on  the  part  of  the  patient  may  be  saved  by  reamputation, 
and  a  far  better  result  is  obtained  by  performing  an  entirely  fresh 
amputation  and  fashioning  new  flaps  than  by  simply  opening  up  the 
wound  and  repacking  a  portion  of  the  bone.  If  such  a  partial  ope- 
ration is  done,  the  nerves  are  still  left  implicated  in  the  cicatrix  and 
fresh  adhesions  between  the  layer  and  the  bone  are  very  apt  to  occur; 
hence  in  all  cases,  except  possibly  in  those  in  which  a  reamputation 
would  involve  the  loss  of  a  joint,  it  is  better  to  fashion  fresh  flaps  which 
do  not  contain  any  scar  tissue.  Where,  however,  an  important  joint, 
such  as  the  knee-joint,  may  have  to  be  sacrificed,  if  fresh  flaps  are  to  be 
made,  or  in  case  the  patient  objects  to  further  amputation,  recourse 
should  be  had  to  exfoliation  of  the  tissue  by  means  of  an  ointment  of 
resorcin,  one  dram  to  the  ounce,  followed  by  applications  of  zinc  oxid, 
bismuth  subnitrate,  or  calomel.  If  these  do  not  suffice  to  heal  the 
stump,  the  removal  of  a  portion  of  the  bone  after  opening  up  the  old 
cicatrix  may  prove  efficient. 

Conical  Stumps.— The  so-called  conical  stumps  result  from  one 
of  three  causes.     In  the  first  place,  the  flaps  may  have  been  so  badly 


AMPUTATIONS. 


375 


planned  at  the  time  of  the  operation  that  they  could  be  brought  with 
difficulty  over  the  end  of  the  bone,  the  result  being  that  if  the  muscles 
contract  or  slougli  the  skin  becomes  more  and  more  tightly  stretched 
over  the  end  of  the  bone,  and  the  stump  therefore  becomes  conical. 
Secondly,  the  condition  may  result  from  excessive  sloughing  or  con- 
traction of  the  muscles  after  an  amputation  in  which  the  flaps  have 
been  accurately  fashioned  at  the  time  of  the  operation.  This  frequently 
occurs  in  muscles  of  subjects  in  whom  healing  by  first  intention  has 
failed.  Lastly,  it  is  a  common  occurrence  in  young  subjects  in  whom 
a  perfectly  successful  amputation  has  been  performed  through  bones 
in  a  condition  of  active  growth.  The  stump  gradually  becomes  more 
and  more  conical.     As  time  goes  on,  this  condition  appears  to  depend 


Fig.  io6. — Tuberculous  Disease  of  the       Fig.  107. — Hernia  of  the   Testicles 
Epididymis  with  Miliary  Deposits  following  Tuberculous  Disease; 

in  the  Testes. — (Moullin.)  Removed  from  Infant,  ^t.  Two. — 

{Moullin.) 


on  want  of  proper  relation  between  the  development  of  the  soft  parts 
generally  and  the  growth  of  the  bone.     (Cheyne.) 

Treatment. — The  only  rational  treatment  is  to  open  the  wound  and 
to  remove  as  much  bone  as  may  be  necessary  to  make  a  satisfactory 
stump.  The  amount  or  extent  of  bone  removed  must,  of  course,  vary 
with  the  age  of  the  patient.  An  older  person  will  not  require  so  great 
a  removal  as  a  younger  person,  in  whom  the  bone  may  be  expected 
to  grow  considerably. 

Postoperative  Changes  Following  Amputations. — The  muscles 
become  atrophied,  and  their  divided  extremities  are  found  to  be  em- 
bedded in  a  mass  of  sound  fibrous  tissue.     Those  whose  functions  are 


376 


POSTOPERATIVE    TREATMENT. 


abolished  are  more  or  less  entirely  converted,  in  process  of  time,  into 
connective  tissue.  Such  as  retain  any  capacity  for  action  retain  to  a 
corresponding  extent  some  muscular  structure. 

The  divided  bone  becomes  rounded  off;  the  medullary  canal  is  closed 
either  by  bone  or  by  fibrous  tissue.  The  extremity  becomes  either 
atrophied  and  pointed,  or  presents  an  abnormal  enlargement  due  to  a 
development  of  bone  from  the  periosteum.  The  new  bone  in  some 
stumps  forms  a  button  or  mushroom-like  extremity  for  the  shaft.  In 
other  instances  the  new  bone-formations  are  scanty  and  spicular,  and 
play  the  part  of  foreign  bodies  in  the  stump. 

The  whole  shaft  of  the  bone  wastes.     After  an  amputation  through 

the  knee  the  femoral  condyles  may 
entirely  disappear;  and  in  an  amputa- 
tion above  that  joint,  not  only  may  the 
shaft  and  trochanters  become  evenly 
atrophied,  but  this  retrogressive  change 
may  extend  to  the  pelvic  bones  of  the 
same  side.  After  a  disarticulation  the 
cartilage  left  upon  the  bone  atrophies  and 
becomes  fibrous,  or  entirely  disappears  in 
the  course  of  years. 

The  nerves  undergo  a  like  atrophic 
process.     The  true  nerve-fibers  disappear 
to  a  variable   extent,   and  are  replaced 
by  connective  tissue.     This  change  may 
extend  to  the  spinal  cord  and  even  to  the 
nerve  columns  concerned.     The  divided 
extremities  of  the  nerves  may  become  en- 
larged and  form  considerable  bulbous  terminations.    It  may  be  here 
said,  however,  that  this  condition  is  not  necessarily  associated  with  ten- 
derness of  the  stump. 

The  collateral  circulation  is  soon  restored  in  the  limb  after  the  high 
division  of  the  main  artery.  That  trunk  in  time  attains  to  such  dimen- 
sions as  are  demanded  by  the  vascular  needs  of  the  part.  Some  years 
after  an  amputation  at  the  hip  by  an  anterior  flap  the  portion  of  the 
femoral  artery  left  in  the  stump  will  probably  be  no  larger  than  the 
radial.  The  wasting  of  the  main  arterial  trunk  may  be  attended  by  an 
overdevelopment  of  certain  of  its  branches,  so  that  after  a  lapse  of  time 
the  principal  artery  may  be  difiicult  to  identify  on  dissection. 


Fig.   io8. — Disarticulation    at 

THE  Shoulder. 
a,  Oval  method;  b,  method  by  del 
toid  flap. — {Dennis.) 


AMPUTATIONS.  377 

AMPUTATION  AT  SHOULDER-JOINT. 

After-treatment. — A  drainage-tube  will  be  required,  as  a  con- 
siderable amount  of  fluid  commonly  escapes  from  the  synovial  mem- 
brane which  is  left  behind.  This  complication  may  be  avoided  by 
dissecting  the  membrane  out  carefully  at  the  time  of  the  operation. 
Pressure  should  be  applied  to  the  outer  flap  after  the  stitches  have  been 
introduced,  in  order  that  the  great  cavity  left  beneath  the  acromion  may 
be,  as  far  as  possible,  obliterated. 

The  method  advised  by  Farabeuf  for  the  adjustment  of  the  wound 
after  Larrey's  operation  is  very  excellent.  A  modified  Velpeau  dressing 
or  a  Desault  bandage  may  be  applied.  The  median  part  of  the  wound 
is  united  by  sutures  as  usual.  The  lower  extremity  is  left  open,  to 
permit  of  efficient  and  simple  drainage.  The  upper  portion  of  the  wound 
is  not  united  by  sutures,  but  the  edges  of  the  incision  are  brought  to- 
gether by  a  compress.  This  compress,  which  is  applied  on  the  outer 
aspect,  not  only  supports  the  wound,  but  also  forces  the  integuments 
under  the  acromion,  and  obliterates  the  hollow  about  the  glenoid  fossa.' 
The  patient's  thorax  should  be  kept  raised  and  the  body  inclined  a  Httle 
toward  the  injured  side. 

INTERSCAPULOTHORACIC  AMPUTATION. 
After-treatment. — The  wound,  when  closed  vdth  sutures,  forms 
an  oblique  line  running  from  above  downward,  outward,  and  backward. 
A  large  pocket  is  left  in  the  stump,  in  which  inflammatory  exudations 
may  readily  collect.  This  pocket  should  be  obliterated  by  pressure, 
a  matter  best  accomplished  by  covering  the  wound  with  iodoform  gauze, 
over  which  the  pressure  of  a  bandage  is  brought,  or  the  open  method  of 
treatment  may  be  employed.  If  this  is  well  effected,  and  if  no  diseased 
or  damaged  tissue  has  been  left  behind,  a  drainage-tube  is  not  required. 
The  patient  should  be  kept  well  raised  up  in  bed.  There  is  a  special 
risk  of  pneumonia  after  this  operation. 

AMPUTATIONS  AT  THE  HIP-JOINT. 
After-treatment.— After  the  operation  all  necessary  means  should 
be  taken  to  prevent  severe  shock.  The  head  should  be  kept  low,  the 
body  well  covered  with  blankets  and  kept  warm  by  a  hot  bottle,  and,  if 
necessary,  enemas  of  brandy,  or  salt  solution  and  w^hisky  or  hot  coffee 
may  be  administered.     Intravenous  injection  of  saline  solution  may  be 


378  POSTOPERATIVE    TREATMENT. 

necessary  during  or  after  the  operation  and  strychnin  may  be  given 
hypodermatically. 

By  means  of  a  suitable  cradle  the  stump  can  be  left  uncovered  and 
the  dressings  be  exposed  to  the  air.  The  stump  should  be  supported 
upon  a  firm  pillow  or  cushion,  care  being  taken  that  no  pressure  is 
exerted  upon  the  wound. 

If  every  care  is  taken,  the  great  wounds  left  by  these  operations  will 
heal  throughout  by  first  intention.  There  is  always  considerable  dis- 
charge of  serosanguinolent  matter  from  the  large  wound  surface.  In 
the  racket  operations,  and  in  Guthrie's  disarticulation,  drainage  may  be 
secured  by  omitting  a  suture  or  so  at  the  most  dependent  point  of  the 
wound.  In  the  transfixion  operation  by  anteroposterior  flaps  a  drainage- 
tube  will  most  probably  be  required. 

As  tension  sometimes  arises  from  simple  extravasation  of  blood 
which  interferes  materially  with  healing,  Senn  recommends  the  intro- 
duction of  an  absorbable  capillary  drain  at  the  lower  angle  of  the  wound. 
A  strand  or  two  of  catgut  twisted  into  a  cord  answers  an  admirable 
purpose,  affording  a  sufficient  drainage  without  interference  with  heal- 
ing, and  requires  no  change  or  interference  with  the  dressings. 

The  first  dressing  should  be  voluminous  and  firmly  secured  by  an 
elastic  bandage  forming  a  figure-of-8  around  the  pelvis.  On  its  inner 
and  front  aspect  the  dressing  should  be  covered  with  jaconet  or  rubber 
tissue.  It  is  important  to  defer  the  changing  of  these  dressings  for  three 
or  four  days  if  possible,  as  it  may  increase  the  shock.  There  may  be 
retention  of  urine,  requiring  the  use  of  a  soft  catheter. 

The  weight  of  the  flaps  renders  it  important  that  the  sutures  should 
not  be  removed  too  soon,  and  after  their  removal  it  will,  as  a  rule,  be 
found  necessary  to  support  the  flaps  by  strapping. 

Care  must  be  taken  that  the  dressings  are  not  soiled  by  urine  or 
feces,  and  that  bed-sores  do  not  form  over  the  sacrum  or  the  trochanter 
of  the  opposite  side.  As  the  action  of  the  bowels  may  soil  the  dressings, 
it  is  best  to  keep  them  from  acting  for  four  or  five  days  by  a  small  opiate. 

Prosthetic  Considerations. — The  average  American  surgeon 
amputates  solely  on  the  principle  of  saving  "all  that  is  possible,"  thus 
making  in  the  majority  of  amputations  a  nearly  hopeless  case  for  the 
prosthetist,  and  in  many  instances  leaves  the  crippled  patient  to  the  fate 
of  wearing  an  artificial  limb  only  with  great  inconvenience  and  dis- 
comfort. 

European  surgeons  are  far  in  advance  in  this  respect,  and  after 


AMPUTATIONS. 


379 


prolonged  scientific  observation  and  experiment  seem  to  have  grasped 
the  importance  of  operating  from  a  functional  as  well  as  an  anatomic 
standpoint,  thus  assisting  the  manufacturer  of  artificial  devices  in  adding 
to  the  future  comfort  and  welfare  of  their  patients. 

Of  the  few  American  surgeons  now  in  accord  with  these  advanced 
ideas,  Nicholas  Senn  is  one  of  the  most  prominent.  In  a  late  surgical 
treatise  in  his  able  article  on  the  general  technic  of  amputations  he 
writes  as  follows: 

"In  all  amputations  below  the  base  of  the  thigh' the  functional  result 
must  be  taken  into  serious  consideration  in  determining  upon  the  site 
of  the  operation.  Disarticulation  at  the  knee-joint  has  but  few  advocates 
at  the  present  time  because  the  resulting  stump  is  bulbous  and  ill  adapted 
for  the  wearing  of  an  artificial  limb.     In  amputations  through  the  upper 


Fig.  109. — Wyeth's  Amputation  at  Hip. — {Brewer.) 

part  of  the  leg  it  must  not  be  forgotten  that  a  stump  four  inches  long  is 
the  shortest  one  that  enables  the  patient  to  w^ear  an  artificial  limb.  It 
is  such  a  stump,  too,  that  will  be  most  serviceable  in  wearing  a  peg-leg, 
which,  among  the  poorer  classes,  is  largely  depended  upon  for  loco- 
motion. If  an  amputation  has  to  be  done  above  this  level,  the  next 
point  of  selection  is  through  the  base  of  the  condyles.  For  this  operation 
the  surgeon  should  select  the  Gritti-Stokes'  transcondyloid  osteo- 
plastic amputation,  which  yields  an  ideal  conic  stump,  weU  fitted  for  the 
wearing  of  an  artificial  limb."    (Senn.) 

"Whenever  admissible,  in  all  amputations  of  the  lower  extremity 
above  the  ankle-joint,  the  operation  should  be  made  at  a  point  and  in 
such  a  manner  as  to  secure  a  conic  stump,  so  keenly  appreciated  by 
every  manufacturer  of  artificial  limbs,  and  subsequently  by  the  patient. 


380  POSTOPERATIVE    TREATMENT. 

It  must  be  remembered  that  when  the  patient  comes  to  wear  an  artificial 
limb,  the  weight  of  the  body  should  not  fall  upon  the  end  of  the  stump, 
but  upon  its  sides,  something  that  can  be  fully  and  satisfactorily  accom- 
plished only  if.the  shape  of  the  stump  is  conic." 

"This  can  be  illustrated  also  by  injury  or  disease  of  the  ankle-joint 
and  tarsus  necessitating  amputation.  The  pathologic  indications  may 
be  fully  met  by  Syme's  amputation  through  the  ankle-joint,  but  the 
resulting  stump  would  be  far  less  useful  to  the  patient  than  if  the  amputa- 
tion had  been  made  at  the  point  of  selection — that  is,  at  the  junction  of 
the  middle  and  lower  third  of  the  leg."  In  this  connection  Fred  T. 
Murphy,  after  extended  inquiry  into  the  subsequent  history  of  amputa- 
tion cases,  says :  Partial  amputations  of  the  foot  or  amputations  of  the 
ankle-joint,  except  under  unusual  conditions,  are  not  as  satisfactory  as 
those  above  the  ankle-joint.  Tibial  stumps  between  six  and  eight 
inches  long  are  the  most  serviceable.  Amputations  through  the  knee- 
joint  are  inferior  to  those  just  above  the  condyles.  The  longer  the 
thigh  stump,  the  better,  provided  the  condyles  have  been  removed.  In 
general,  in  tibial  amputations  down  to  four  inches  and  in  thigh  am- 
putations down  to  five  inches,  sacrifice  bone  in  order  to  obtain  good 
muscle-flaps. 

AMPUTATION  OF  THE  THIGH. 

After-treatment. — The  thigh  should  be  raised  and  supported 
upon  a  firm  pillow  or  cushion,  to  which  it  should  be  lightly  secured. 
The  limb  should  be  placed  in  the  abducted  position.  The  extremity 
of  the  stump  should  project  beyond  the  end  of  the  pillow.  It  will  be 
thereby  exempted  from  pressure,  and  drainage  will  not  be  interfered 
with.  A  supporting  splint  is  not  required  in  these  amputations,  al- 
though it  may  sometimes  be  employed  with  advantage  after  the  cir- 
cular operation  and  in  amputations  through  the  lower  part  of  the  limb. 

A  few  sutures  should  be  omitted  at  the  most  dependent  angle  of  the 
wound,  to  allow  for  drainage — or,  better  still,  a  short  tube  and  piece 
of  gauze  should  be  inserted  at  that  situation.  The  oozing  during  the 
first  twenty-four  hours  is  considerable.  In  no  case  should  a  large 
drainage-tube  be  drawn  right  through  the  depths  of  the  wound  from 
one  extremity  of  the  incision  to  the  other. 

As  the  flaps  are  large  and  heavy,  the  sutures  should  not  be  removed 
too  soon.  After  their  removal,  the  flaps  may  need  to  be  supported  for 
a  while  by  strapping. 


AMPUTATIONS. 


381 


If  silk  ligatures  have  been  applied  to  the  arteries,  no  attempt  should 
be  made  to  remove  them  prior  to  the  fourteenth  day,  after  which  date 
at  the  time  of  the  daily  dressings  the  ligatures  in  turn  shoulr]  be  gently 
pulled  upon,  but  no  harsh  effort  should  be  made  to  remove  them.  It 
frequently  happens  that  silk  ligatures  will  remain  quite  firmly  embedded 
in  the  tissues,  causing  very  little  disturbance,  for  weeks  or  months. 
Should,  however,  after  several  weeks  a  slight  tenderness  or  sloughing 
occur,  the  patient  should  be  anesthetized  and  the  ligatures  forcibly 
removed. 


AMPUTATION  OF  THE  FINGERS  AND  THUMB. 

In  amputating  fingers  the  flaps  should  be  made  so  that  the  cicatrix 
should  come  upon  the  dorsum  of  the  hand  with  the  least  possible  inter- 
ference with  the  palm. 

Treatment. — The  wounds  after 
these  operations  as  a  rule  heal  well, 
but  are  often  very  painful.  As  the 
skin  of  palmar  flaps  is  usually  thick 
and  stiff,  the  sutures  should  be  well 
applied,  and  should  not  be  too  soon 
removed.  Silkworm-gut  sutures  are 
well  adapted  for  these  operations. 
The  hand  should  be  kept  elevated, 
and  never  allowed  to  hang  down,  and 
care  must  be  taken  that  too  tight 
bandages  are  not  applied  about  the 
wrist. 

In  the  larger  operations,  especially 
when  a  palmar  flap  has  been  cut, 
the  hand  should  be  supported  upon  a 
splint  in  order  to  arrest  the  movements  of  the  wrist.  As  a  rule, 
no  drainage-tube  is  required,  a  small  piece  of  the  selvage  of  iodoform 
gauze,  or  a  few  strands  of  horsehair  or  of  silkworm-gut,  being  usually 
all  that  is  necessary;  but  when  the  metacarpus  is  concerned,  and 
when  the  tissues  of  the  palm  have  been  lacerated  or  torn,  a  small  tube 
may  with  benefit  be  introduced  and  retained  for  some  twenty-four  or 
forty-eight  hours.  It  should  be  remembered,  particularly  in  dealing 
with  laboring-men,  that  to  conserve  every  particle  of  tissue  which 
may  be  of  subsequent  use  to  the  patient  is  the  highest  art  of  surgi- 


FiG.  110. — Open   Incision  and  Su- 
ture OF  Sac. — {Moullin,  after  V. 

Volkmann.) 


382 


POSTOPERATIVE    TREATMENT. 


cal  treatment.     In  case  fingers  have  been  severed  by  accident,  we  are 
not  to  sacrifice  bone  in  order  merely  to  secure  flaps.     By  this  method 


Fig.  III. 


Fig.  112. 


AMPUTATIONS.  383 

healing  will  take  place  more  slowly,  but  the  additional  length  of  the 
fingers  more  than  compensates  for  the  delay. 

The  partial  operations  following  upon  crushes  of  the  hand  must 
be  treated  upon  the  same  principles  as  apply  to  complicated  or  con- 
tused wounds. 

Figs.  Ill  and  112  represent  postoperative  results  in  cases  where 
the  amputation  was  performed  regardless  of  any  fixed  rule  or  special 
method,  and  made  solely  with  the  view  to  preserving  as  much  tissue 
as  possible,  and  forming  strong,  useful  hands. 

AMPUTATIONS  OF  THE  TOES  OR  PORTIONS  OF  THE  FOOT. 

Considerations  of  Asepsis. — It  must  be  confessed  that  the  wounds 
of  these  operations  do  not  always  heal  so  kindly  as  might  be  expected, 
and  often  compare  unfavorably  with  like  wounds  in  the  hand.     In  a  few 
cases  this  may  be  due  to  the  fact  that  the  opera- 
tion is  an  imperfect  one — a  mere  trimming  of  a 
mangled  part — and  is  the  outcome  of  a  desire  to 
remove  as  little  tissue  as  possible. 

The  less  free  circulation  of  the  part,  and  the 
circumstance  that  the  wound  is  less  conveniently 
placed  for  drainage,  may  serve  in  other  cases  to 
explain  the  tardier  healing  when  compared  with 
operation  wounds  of  the  fingers.    There  is  little 
doubt,    however,    that    the  chief  reason   lies  in 
imperfect  disinfection  of  the  skin  before  operat- 
ing.      The    clefts    between    the    toes    are   un-        of  To-e.— {Hare.) 
rivaled    breeding-grounds  for   bacteria.      Before 
an  amputation  in  this  region  the  most  sedulous  care  should  be  paid  to 
repeated  disinfection  with  alcoholic  solution  of  mercury  biniodid  or 
of  carbolic  acid.     If  the  aseptic  precautions  are  thorough,  the  wound 
will  probably  heal  as  well  here  as  in  any  other  part  of  the  body. 

Removal  of  Sutures,  Drainage,  etc.— As  the  skin  of  plantar 
flaps  is  usually  thick  and  stiff,  sutures  should  be  so  applied  as  to  retain  a 
good  hold  of  the  parts.  They  should  not  be  removed  too  soon,  as  the 
flap  may  give  way.  Silkworm-gut  sutures  may  often  be  left  in  for  ten 
or  even  fourteen  days.  The  smaller  amputations  require  ordinarilv 
no  drainage.  In  operations  upon  the  great  toe,  a  fine  tube,  or  a  tube 
split  in  halves,  or  strands  of  silkworm-gut,  or  a  gauze  drain  mav  be  re- 
tained for  the  first  twenty-four  hours.     In  case  of  the  removal  of  the 


384 


POSTOPERATIVE    TREATMENT. 


great  toe,  together  with  its  metatarsal  bone,  the  foot  should  be  allowed 
to  lie  a  little  upon  its  inner  side,  provided  direct  pressure  is  not  made 
upon  the  wound.  When  the  fifth  toe  has  been  removed  in  a  similar 
manner,  the  foot  should  be  inclined  toward  the  opposite  side. 

Position. — The  limb  should  be  kept  exposed  or  outside  of  the  bed- 
clothes. The  leg  should  lie  so  that  the  foot  can  rest  upon  one  or  the 
other  side.  When  the  patient  lies  flat  on  the  back,  the  toes  point  up- 
ward, drainage  is  rendered  almost  impossible,  and  every  facility  is  given 
for  the  gravitation  of  the  effusions  of  the  wound  into  the  depths  of  the 
foot.  If  the  flaps  have  been  carelessly  cut,  if 
the  tendon-sheaths  have  been  left  open,  if  the 
wound  is  not  perfectly  aseptic,  and  if  the  foot 
is  so  placed  that  proper  drainage  is  impossible, 
it  is  no  matter  for  wonder  that  the  stump  does 
not  do  well,  and  that  deep-seated  suppuration 
is  detected  in  the  foot. 

After  Lisfranc's  and  Hey's  amputations 
the  limbs  may  be  allowed  to  lie  upon  one  or 
the  other  side  with  the  knee  flexed.  The  pil- 
low supporting  the  foot  should  be  firm;  the 
stump  may  project  a  little  beyond  the  end  of 
the  pillow,  and  to  this  support  the  leg  may  be 
lightly  secured. 

After  Chopart's  operation  and  after  the  sub- 
astragaloid  amputations  the  stump  should  be 
supported  upon  a  back-splint,  which  is  kept  a 
little  raised  by  a  firm  pillow  or  cushion.  By 
this  means  the  heel-flap  is  supported,  and  the 
OS  calcis  in  the  Chopart  operation  is  to  a  great 
extent  kept  from  altering  its  position.  The 
knee  should  be  a  little  flexed,  and  the  stump 
may  be  inclined  laterally,  so  as  to  favor  drain- 
The    splint   employed     is    an   ordinary     straight    back-splint. 


Fig.  114. — Lines  of  Incis- 
ion FOR  Amputation 
OF  Toes  and  Meta- 
tarsal Bones. — {Stim- 
son.) 


age. 


suitably  padded.  A  pad  is  introduced  beneath  the  tendo  Achillis. 
The  skin  is  protected  by  a  piece  of  guttapercha  molded  to  the  limb 
and  Hned  with  lint.   The  splint  is  secured  by  straps  and  buckles. 

Drainage-tubes  should  not  be  employed  unless  actually  necessary, 
and  should  never  be  passed  right  across  the  angle  of  the  wound,  from 
one  extremity  of  the  incision  to  the  other.     A  small  piece  of  tubing  may 


AMPUTATIONS.  385 

be  introduced  at  each  of  the  two  corners  of  the  wound — as  in  Hey's, 
Lisfranc's,  and  Chopart's  amputations — and  sutures  at  these  points 
may  be  omitted.  In  any  case  the  tubes  should,  under  ordinary  circum- 
stances, be  removed  in  twenty-four  hours. 

In  the  subastragaloid  operations,  when  a  heel- flap  exists, — with  a 
pouch  left  by  the  removal  of  the  os  calcis, — a  hole  may  be  made  through 
the  center  of  that  flap  into  the  pouch,  and  a  short  tube  introduced. 
This  need  not  be  retained  more  than  one  day.  When  the  major  flap  is 
formed  from  the  heel  or  sole,  it  should  be  remembered  that  the  tissues 
of  those  parts  are  usually  tough  and  unyielding,  and  that  consequently 
an  undue  strain  comes  upon  the'  sutures.  These  should  be  deeply 
inserted,  and  should  not  be  removed  too  soon.  In  a  "Symc"  they  may 
often  be  retained  for  ten  days.  After  their  removal  it  may  be  necessary 
to  support  the  flap  with  strips  of  adhesive  plaster. 

Care  must  be  taken  that  the  pad  of  the  splint  does  not  press  unduly 
upon  the  extremity  of  the  stump.  This  splint  serves  to  support  the 
heel-flap,  and,  in  the  case  of  the  intracalcaneal  amputations,  it  helps 
also  to  keep  the  osseous  surfaces  in  contact  and  to  restrain  the  action  of 
the  muscles  of  the  calf. 

The  knee  should  in  all  instances  be  a  little  flexed,  and  the  stump 
may,  when  required,  be  inclined  a  little  laterally,  to  favor  drainage. 


26 


CHAPTER  XVII. 
EXCISIONS  OR  RESECTIONS  OF  JOINTS. 


CHAPTER  XVII. 
EXCISIONS  OR  RESECTIONS  OF  JOINTS. 

EXCISIONS  OF  JOINTS. 

The  Kocher  Method. — The  modem  method  of  typical  excisions 
which  is  most  worthy  of  recommendation  seems  to  us  to  be  the  following : 

1.  To  employ  as  simple  an  incision  as  possible  (Langenbeck),  special 
care  being  taken  not  merely  to  place  it  in  the  intervals  between  the 
muscles,  ligaments,  and  tendons,  but  to  carry  it  down  to  the  bone  in 
such  a  way  that  the  smallest  vessels  and  nerves  can  be  avoided,  and  also 
to  place  it  in  the  frontier  line  between  the  muscles  supplied  by  different 
nerves. 

2.  To  detach  subcortically  the  capsule,  the  periosteum,  and  the 
ligamentous  and  tendinous  attachments,  and  to  remove  all  the  diseased 
bone  with  the  articular  extremities,  should  this  be  deemed  necessary  in 
order  to  obtain  a  better  functional  result.  If  attention  be  paid  to  these 
points  with  strict  aseptic  precautions,  arthrotomy  can  be  undertaken 
with  benefit  in  the  early  and  mild  stages  of  joint  disease.     (Kocher.) 

Essentials  of  After-treatment. — It  is  obvious  that  in  excisions  the 
limb  should  be  immobolized  in  a  plaster  bandage,  so  that  the  new 
articular  ends  may  be  kept  firmly  in  contact  iii  good  position.  Where 
there  is  any  difhculty  in  maintaining  them  in  position,  it  may  be  neces- 
sary to  wire  the  ends  together  in  such  a  way  as  to  retain  them  in  the 
desired  position  without  ultimately  preventing  the  proper  movement. 
Lane  has  made  use  of  this  plan  with  very  good  result  in  old-standing 
affections  of  the  hip-joint.  Healing  usually  occurs  rapidly,  and  if  the 
wound  remains  aseptic,  the  patient  may  begin  passive  movements  in 
fourteen  days  in  the  case  of  the  upper  extremity,  while  in  the  case  of  the 
lower  extremity  he  may  be  allowed  to  go  about  with  the  limb  in  plaster. 
The  sooner  movement  is  begun,  the  better  will  be  the  result,  even  if  it 
is  only  very  slight  movement  inside  a  well-padded  plaster  case.  To 
obtain  early  restoration  of  function  it  is  essential  to  get  rid  of  the 
sensitiveness  of  the  sawed  ends  of  the  bone  as  soon  as  possible.  ^Miere 
ankylosis  is  desired,  as  in  excision  of  the  knee-joint,  firm  fixation  is  the 

•389 


39° 


POSTOPERATIVE    TREATMENT. 


best  means  of  obtaining  tliis  object,  the  limb  being  placed  at  once  in  a 
plaster  cast.  To  obtain  firm  union,  the  bones  must  fit  accurately  to- 
gether, or  they  may  be  wired  or  nailed  together.  To  obtain,  rapidly, 
comparative  insensitiveness  in  the  ends  of  the  bone  in  case  a  movable 
joint  is  aimed  at,  Kocher  adopts  the  following  procedure,  which  he 
terms  "the  dislocation  or  secondary  reposition  method " :  "In  the  elbow 
and  hip,  for  example,  after  resecting  the  ends  of  the  bones  we  bring  them 
into  a  dislocated  position,  so  that  the  sensitive  sawed  ends  of  the  bones 
are  merely  in  contact  with  the  soft  parts ;  after  ten  to  fourteen  days,  when 
the  skin-incision  is  quite  healed,  they  can  be  easily  placed  in  proper 
position.     The  patient  then  begins  at  once  to  move  the  limb,  which  by 


Fig.  115. — Hoppe's  Universal  Adjustable  Splint. 


a,  b,  c.  Steel  or  aluminum  connecting  rod  ;  movable  joint  at  6  ;  d  forearm  splint ; 
e  arm  splint  ;  /  thumb-set  caps  or  screws. 

the  usual  method  he  is  quite  unable  to  do,  however  much  he  may  desire 
to.  It  is  essential,  too,  that  the  movements  of  the  muscles  should  be 
begun  early,  if  the  function  of  the  joint  is  to  be  restored  quickly.  By 
means  of  an  apparatus  provided  with  the  means  of  elastic  flexion  and 
extension,  while  the  axis  of  movement  is  maintained,  the  treatment  is 
greatly  assisted." 

Excision  of  the  Shoulder-joint. — In  excising  the  shoulder-joint 
it  is  very  important  to  remove  as  little  of  the  bone  as  possible,  for  the 
reason  that  it  is  necessary  to  leave  the  attachment  of  the  rotator  muscles 
intact  if  this  can  be  safely  done ;  this  permits  rotation  of  the  arm,  whereas 
after  the  old  operation,  in  which  the  rotators  were  completely  cut  across 


EXCISIONS    OK    RKSKCTIONS    OF    JOINTS.  39I 

and  the  bone  was  sawed  on  a  level  with  the  surj^ical  neck,  the  resulting 
limb  was  very  useless.  Before  the  wound  is  closed  with  stitches  it  is 
advisable  to  insert  a  drainage-tube  at  the  lower  angle  of  the  wound  for 
a  few  days,  as  a  considerable  cavity  is  left  which  may  become  distended 
with  blood  and  scrum.  The  tube  is  usually  removed  about  the  third 
day.  After  the  usual  gauze  dressings  have  been  apj^licfl,  a  large  werlge- 
shaped  pad  is  placed  in  the  axilla  to  prevent  displacement  inwarrl  of 
the  upper  end  of  the  humerus.  It  is  well  also  to  place  a  firm  pad  over 
the  front  of  the  joint,  because  the  upper  end  of  the  bone  is  apt  also  t(j 
be  drawn  forward.  The  wedge-shaped  pad  should  extend  as  far  down 
as  the  elbow,  and  the  forearm  should  be  flexed  and  supported  by  a  splint. 
The  hand  should  not  be  bound  to  the  side. 

After-treatment  (Cheyne-Burchard,  "Manual  of  Surgical 
Treatment"). — So  soon  as  the  wound  is  healed  the  arm  may  be  fixed 
in  proper  position  by  a  starch  or  plaster  bandage,  and  after  two  weeks, 
passive  movements  should  be  begun;  the  period  at  which  the  passive 
movement  should  be  employed  depends  largely  upon  the  healing  of  the 
incision  and  the  amount  of  bone  removed.  If  the  whole  of  the  upper 
end  of  the  humerus  has  been  removed  and  the  rotators  divided,  the 
elbow  should  be  supported  and  the  arm  fixed  for  four  or  five  weeks,  as 
otherwise  a  very  lax  joint  is  likely  to  result.  If,  on  the  other  hand,  the 
operation  we  have  described  is  sufficient,  passive  movement  should  be 
begun  after  the  fourteenth  day.  Special  attention  must  be  paid  to 
preserving  rotation,  which  is  the  movement  most  likely  to  be  lost;  ab- 
duction should  also  be  carefully  attended  to.  The  axillary  pad  and  the 
wrist-sling  should  be  continued  for  six  or  eight  weeks. 

Sir  Frederick  Treves  suggests  the  following:  The  upper  end  of 
the  humerus  is  to  be  brought  into  contact  with  the  glenoid  fossa. 
The  arm  is  secured  to  the  side,  the  hand  rests  in  a  sling.  A  large 
pad  of  cotton- wool  is  introduced  into  the  axilla.  This  pad  is  in- 
tended to  support  the  bone,  to  assist  in  fixing  the  parts,  and  to  counter- 
act the  tendency  which  will  be  exhibited  for  the  upper  end  of  the  humerus 
to  be  drawn  inward  under  the  coracoid  process.  This  displacement 
is  especially  apt  to  occur  when  the  external  rotator  muscles  have  been 
divided,  and  there  is  little  to  withstand  the  action  of  the  pectoralis  major 
and  latissimus  dorsi.  The  size  of  the  pad  must  be  regulated  according 
to  the  needs  of  the  case.  It  should  be  of  triangular  outhne,  with  the 
base  uppermost.  The  pad  is  likely  to  fail,  if  it  fail  at  all,  from  being 
too  small  rather  than  too  large.     No  splint  is  required. 


392  POSTOPERATIVE    TREATMENT. 

Passive  movements  of  the  fingers,  wrist,  and  elbow  may  be  com- 
menced within  a  day  or  two  after  the  operation.  Very  gentle  passive 
movements  of  the  shoulder  may  be  first  attempted  at  the  end  of  some 
fourteen  days.  These  movements  should  consist  of  flexion  and  exten- 
sion, of  slight  rotation,  and  of  still  slighter  abduction.  The  latter  posi- 
tion tends  to  throw  the  end  of  the  bone  inward — or,  rather,  to  assist 
the  disposition  to  that  deviation.  Massage,  electricity,  and  active  move- 
ments will  follow  in  due  course.  The  arm  may  be  allowed  to  hang, 
with  no  other  support  than  a  sling,  at  the  end  of  four  or  five  weeks. 

Results. — The  results  of  this  operation  are  very  satisfactory.  The 
mortality  of  the  operation  is  shght.  More  than  two-thirds  of  the  sub- 
jects of  the  operation  recover,  with  quite  useful  limbs.  In  many  in- 
stances the  restoration  of  function  has  been  remarkable.  As  a  rule, 
flexion  and  extension  are  freely  performed,  and  the  patient  can  lift  con- 
siderable weight.  Adduction  also  is  well  accomplished.  On  the  other 
hand,  rotation  movements  and  abduction  are  feebly  performed.  The 
arm  cannot  be  lifted  beyond  a  right  angle  with  the  trunk.  It  is  after 
the  subperiosteal  operations  that  the  best  results  have  been  obtained. 
There  is  a  tendency,  as  already  stated,  for  the  upper  end  of  the  bone 
to  assume  the  position  occupied  by  the  head  in  subcoracoid  dislocation. 
Ankylosis  appears  to  result  more  frequently  than  a  flail-like  joint. 

Excision  of  Elbow. — ^After-treatment. — Treves  states  that  after 
the  operation  the  limb  must  be  placed  upon  a  suitable  splint  and 
the  bones  so  adjusted  that  the  greater  diameters  of  the  bony  surfaces 
correspond  and  do  not  cross.  The  hand  should  be  in  the  mid-position 
between  pronation  and  supination,  and  the  elbow  be  very  slightly  bent 
— so  slightly  that  the  forearm  will  be  nearer  to  the  extended  posture 
than  to  the  position  it  occupies  when  at  right  angles  to  the  arm.  The 
precise  angle  recommended  by  most  surgeons  is  an  angle  of  135  degrees. 

Very  many  forms  of  splint  have  been  devised.  The  main  require- 
ments of  such  appliances  are  that  they  may  be  light,  strong,  rigid,  easily 
kept  clean,  and  do  not  interfere  with  the  drainage  and  dressing  of  the 
wound.  In  many  cases  a  splint  may  be  dispensed  with,  the  support  of 
the  dressings  and  a  pillow  being  sufficient. 

Hausmann's  combined  splint  for  excision  of  the  wrist  or  elbow 
answers  its  purpose  well,  and  also  permits  the  joint  to  be  exercised 
without  the  splint  being  removed.  The  fingers  should  be  free.  The 
splint  and  limb  may  be  at  first  suspended  from  a  cradle,  or  supported 
upon  a  pillow  with  sand-bags. 


EXCISIONS   OR   RESECTIONS   OF   JOINTS. 


393 


It  must  be  borne  in  mind  that  there  is  some  disposition  for  the  bones 
of  the  forearm  to  be  displaced  backward,  that  too  wide  a  distance  be- 
tween the  bones  may  lead  to  a  flail-like  joint,  and  that  if,  on  the  other 
hand,  the  sawed  surfaces  be  kept  in  close  contact,  in  young  subjects 
bony  ankylosis  may  ensue.  The  relative  position  of  the  Vjones  can 
always  be  estimated  by  a  skiagram. 

In  general  terms,  it  may  be  said  that  to  insure  a  false  joint  the  bones 
should  be  separated  for  the  distance  of  half  an  inch.  After  a  successful 
excision  by  the  subperiosteal  method  in  healthy  subjects  the  disposition 
to  ankylosis  is  considerable.  As  ankylosis  is  especially  to  be  feared 
in  children,  the  limb  may  be  put  up  from  the  first  on  a  right-angle  splint, 
such  as  that  recommended  for  the  purpose  by  Jacobson,  with  a  movable 
or  adjustable  joint  at  the  elbow.  When  also  a  considerable  quantity 
of  bone  has  been  removed,  the 
use  from  the  commencement 
of  a  rectangular  splint  is  ad- 
vised by  many. 

Passive  movements  of  the 
fingers  and  shoulder,  and 
flexion  and  extension  of  the 
wrist,  should  be  commenced 
as  soon  as  possible  after  the 
operation — possibly  by  the 
third  day — and  should  be  con- 
tinued daily.  Passive  move- 
ments of  the  elbow  may  commence  about  the  tenth  day,  pro^'ided 
that  the  healing  process  has  proceeded  favorably  and  the  meas- 
ure can  be  borne  by  the  patient  without  undue  pain.  In  children 
such  movements  may  at  first  be  required  to  be  carried  out  under 
an  anesthetic.  When  four  or  five  weeks  have  elapsed,  the  forearm 
may  be  gradually  brought  up  until  it  forms  a  right  angle  to  the  arm. 
At  the  end  of  six  or  eight  weeks  the  splint  may  be  dispensed  wdth,  and 
the  movements  of  the  elbow  should  be  free.  Active  movements,  aided 
by  massage  and  galvanism,  should  now  be  ad\dsed;  and  withm  four 
months  from  the  time  of  the  operation  the  new  joint  should  have 
acquired  solidity  and  be  capable  of  exliibiting  a  free  and  extensive 
range  of  movement. 

Excision  of  the  elbow  has  led,  on  the  whole,  to  very  satisfactor}" 
results,  and  in  a  large  proportion  of  the  more  favorable  cases  the  results 


Fig.  1 1 6. — Elbow  Splestt. — (Strohmeyer.) 


394 


POSTOPERATIVE    TREATMENT. 


have  been  most  admirable.  Even  if  ankylosis  occurs  at  a  right  angle, 
the  limb  is  in  a  better  condition  than  it  was  while  diseased.  In  the 
more  unfortunate  instances  repair  is  imperfect  for  various  reasons,  and 
a  very  loose  false  joint,  resulting  in  a  flail-like  limb,  is  the  final  production. 
Even  in  such  a  case  a  good  deal  may  be  done  by  means  of  a  suitable 
splint;  the  apparatus  shown  in  Fig.  ii6  has  proved  most  efficient.  It 
consists  of  two  pieces,  one  of  which  grasps  the  upper  arm  and  the  other 
the  forearm,  the  two  being  connected  by  a  metal  band  over  each  side  of 
the  elbow,  jointed  to  permit  of  flexion  and  extension.  This  apparatus 
prevents  lateral  mobility,  and,  if  worn  for  some  months,  it  is  quite 
possible  that  a  joint  which  was  at  first  very  lax  may  finally  be  quite 
satisfactory. 

RESECTIONS  OF  JOINTS. 

Resection  of  the  Wrist-joint. — After  resection  of  the  wrist-joint 
the  wrist  should  be  dressed  as  nearly  straight  as  possible,  Esmarch's 


interrupted  splint  (Fig.  117)  being  applied.     The  results  of  this  opera- 
tion vary  very  much,  and  on  the  whole  are  not  satisfactory.     The  splint 


Fig.  118. 


-Proper  Method  of  Applying  Bandage  After   Operations  on   Fore- 
arm, Wrist,  or  Hand. 


must  be  worn  for  a  very  considerable  time, — three  to  six  months, — and 
there  is  a  tendency  for  the  hand  to  fall  into  a  position  of  adduction. 


EXCISIONS    OR   RESECTIONS    OF   JOINTS. 


395 


Passive  movement  of  the  fmgers  is  begun  on  the  second  day,  whether 
the  inflammation  has  subsided  or  not,  and  continued  daily.  Each  joint 
should  be  flexed  and  extended  to  the  fullest  extent  possible  in  health, 
the  metacarpal  bone  being  held  quite  steady  to  avoid  disturbing  the 
wrist.  By  this  means  the  suppleness  gained  by  breaking  down  the 
adhesions  under  chloroform  is  maintained. 

Pronation  and  supination,  flexion  and  extension,  abduction  and 
adduction,  must  be  gradually  encouraged  as  the  new  wrist  acquires 


Fig.  119. — Thomas's  Hip  Splint. 


Fig.  120. — Schatfer's  Hip  Splint. 


firmness.  When  the  hand  has  acquired  sufficient  strength,  freer  play 
for  the  fingers  should  be  allow^ed  by  cutting  off  all  the  splint  beyond  the 
knuckles.  Even  after  the  hand  is  healed,  a  leather  support  should  be 
worn  for  some  time,  accurately  molded  to  the  front  of  the  limb,  reaching 
from  the  middle  of  the  forearm  to  the  knuckles,  and  sufficiently  turned 
up  at  the  ulnar  side.  This  is  retained  in  situ  by  lacing  over  the  back 
of  the  forearm. 

Resection  of  Hip. — General   Considerations. — ^After  the  ex- 


396  POSTOPERATIVE    TREATMENT. 

cision  and  arthrectomy  have  been  completed,  the  hemorrhage  carefully 
arrested,  and  the  acetabulum  thoroughly  cleaned  with  a  sharp  spoon,  the 
trochanter  is  replaced  and  fixed  in  position  with  an  aseptic  bone  or 
ivory  nail,  aided  by  sutures  of  catgut  embracing  the  periosteum  and  the 
dense  fascia.  In  a  number  of  cases  Senn  has  relied  on  suturing  with 
catgut  exclusively  in  immobilizing  the  trochanter,  and  had  the  satisfac- 
tion of  observing  that  the  trochanter  was  perfectly  held  in  place  until 
bony  union  was  sufficiently  firm  to  dispense  with  direct  means  of  fixation. 
The  acetabulum  is  drained  with  a  tubular  drain  and  iodoform  gauze, 
which  are  brought  out  through  a  separate  opening  behind  the  resection 
wound.  The  dressing  must  be  large,  embracing  the  upper  half  of  the 
thigh  and  the  same  side  of  the  pelvis  as  far  as  the  crest  of  the  ilium. 
As  a  primary  immobilization  dressing  a  long  external  splint  with  foot- 
board and  extension  by  weight  or  straps  will  be  most  comfortable  and 
efficient  (Fig.  119  and  Fig.  120).  So  soon  as  the  patient  is  able  to  leave 
his  bed,  a  plaster-of-paris  dressing  is  relied  upon  in  securing  fixation 
and  in  guarding  against  undue  shortening. 

Hueter's  anterior  incision  for  resection  is  now  rarely  employed  except 
for  exposing  the  acetabulum  in  congenital  dislocation  of  the  hip  or  in 
operations  upon  children.  The  posterior  incision  gives  much  more 
room  and  admits  of  better  drainage,  and  is  now  universally  adopted  as 
giving  better  results. 

After- TREATMENT. — When  the  patient  is  placed  in  bed,  extension 
should  be  employed,  a  weight  of  three  or  four  pounds  being  used  for  a 
child,  the  limb  being  in  the  abducted  position,  all  motion  and  rotation 
being  prevented  by  a  properly  adjusted  splint  (see  Fig.  90).  A  Liston's 
long  sphnt  is  very  frequently  used,  and  applied  to  the  sound  side  from 
the  axilla  to  beyond  the  toes,  so  as  to  prevent  any  flexion  of  the  hip-joint. 
The  patient  should  be  laid  upon  a  mattress  divided  in  three  parts  in 
order  that  the  central  portion  may  be  removed  for  nursing  purposes 
without  necessitating  any  disturbance. 

The  extension  and  fixation  of  the  limb  should  be  kept  up  for  about 
six  weeks;  at  the  end  of  that  time  a  Thomas's  hip  splint  (see  page  395) 
may  be  employed.  This  should  be  bent  well  outward  opposite  the  joint 
so  as  to  keep  the  limb  in  the  abducted  position;  the  splint  should  be 
provided  with  a  pelvic  band.  In  quite  young  children,  who  are  very 
difficult  to  keep  quiet,  either  a  double  Thomas's  splint  well  padded 
or  a  simple  Phelps's  box  splint  will  be  better  than  the  single  splint. 
Contrary  to  the  common  recommendation,  we  very  strongly  advise  that 


EXCISIONS   OR  RESECTIONS   OF   JOINTS. 


397 


the  patient  should  not  be  allowed  to  walk  or  to  bear  any  weight  on 
the  limb  for  several  months — at  least  six  or  eight  after  the  operation, 
when  the  patient  may  be  placed  in  an  ambulatory  splint.  If  this  be  done, 
the  consolidation  of  the  structures  in  the  neighborhood  of  the  joint  will 


Fig.  12  1. — Ambulatory  Splint. 


give  a  much  firmer  joint  than  is  otherwise  obtainable.  It  is  very  seldom 
that  anything  like  bony  ank3dosis  occurs,  but  if  a  movable  joint  be 
desired,  this  may  be  assured  by  performing  passive  movement  of  the  hip 
through  a  limited  range  twice  a  week  after  the  wound  has  healed.     The 


398 


POSTOPERATIVE    TREATMENT. 


patient  need  not  be  kept  in  bed  longer  than  the  third  or  fourth  week.  He 
may  be  allowed  to  get  about  on  crutches  with  an  ambulatory  splint, 
or  a  high. boot  on  the  sound  foot  so  as  to  avoid  any  risk  of  the  affected 
fool  being  put  -to  the  ground. 

When  excision  is  employed  in  the  later  stage  of  the  disease,  where  the 
disease  has  been  cured  and  the  operation  is  only  done  for  the  deformity, 
mere  removal  of  the  head  of  the  bone  is  all  that  is  necessary;  the  removal 
of  the  capsule  is  not  called  for,  as  the  disease  has  disappeared.  The 
object  of  the  operation  in  these  cases  is  simply  to  get  rid  of  the  head  of 
the  bone  so  as  to  obtain  a  movable  joint. 


Fig.    12  2.— Anterior  Leg   Splint,    for  Resection   of   the   Knee-joint,    Fitting 

Either  Side. 


Fig.  123. — Posterior  Leg  and  Thigh  Splint,  for  Resection  of  the  Knee-joint, 

Fitting  Either  Side. 

If  sepsis  occurs,  the  after-treatment  is  tedious  and  uncertain,  and 
frequently  demands  considerable  mechanical  skill  in  the  application  of 
splints,  and  at  the  same  time  permit  surgical  dressings  to  be  applied  when 
the  wound  is  suppurating.  The  open-wound  method  of  treatment  is 
always  preferable,  and  the  after-treatment  does  not  vary  from  methods 
already  described  under  the  head  of  "Treatment  of  Septic  Wounds." 
In  these  prolonged  cases  the  ambulatory  splint  (Fig.  121)  not  only 
assists  in  the  radical  cure,  but  renders  the  patient  more  comfortable  and 
permits  him  to  be  up  and  around. 

Excision  or  Resection  of  the  Knee-joint. — The  after-treat- 
ment is  of   the  utmost  importance,  is  tedious,  and  often  surrounded 


EXCISIONS    OK    RESECTIONS    OF    JOINTS.  399 

with  difficulties.  There  is  a  tendency  to  displacement,  and  notably 
to  a  displacement  of  the  tibia  backward.  If  sound  healing  does  not 
take  place,  the  limb  is  worse  than  useless,  and  the  flail-like  limb  that 
may  result  is  of  less  service  to  the  patient  than  a  good  arlirjf;ial  leg. 

The  limb  must  ])e  put  uj)  perfectly  straight, — i.  e.,  in  the  jKjsition 
of  complete  extension, — and  for  the  purpose  of  fixing  it  many  surgeons 
employ  plaster-of-paris.  The  rigid  dressing  formed  of  this  material 
is  not  entirely  satisfactory.  It  may  exercise  an  unequal  pressure  upon 
the  parts,  and  may  lead  to  edema,  etc.  Discharge  may  find  its  way 
between  the  splint  and  the  limb,  the  dressing  is  difficult  to  remove,  and 
even  when  large  "windows"  are  provided  the  inspection  of  the  part 
can  never  be  so  complete  as  it  should  be  (Fig.  91). 

A  splint  should  be  provided  which  will  allow  the  bones  to  be  kept 
in  good  position,  will  permit  free  inspection  and  examination  of  the 
wound,  and  will  not  interfere  with  dressing  and  drainage  should  drainage 
be  necessary. 

The  ordinary  posterior  leg-and-thigh  wire  splint  (Figs.  122,  123)  for 
resection  of  the  knee-joint  is  quite  popular  with  some  surgeons,  but  the 
wire  when  the  heel  touches  should  be  removed,  cut  or  bent  out  to  avoid 
pressure.  It  is  retained  and  held  in  place  by  gypsum  bandages  to  im- 
mobolize  the  part  above  and  below  the  knee.  The  knee  itself  is  dressed 
and  so  protected  that  it  can  be  examined  without  disturbing  the  other 
dressings.  It  is  well  that  the  splint  should  be  suspended.  Marsh 
points  out  that  "the  plan  of  firmly  bandaging  the  lower  end  of  the  femur 
to  the  back-splint  leads  to  great  swelling  about  the  wound,  and  materi- 
ally retards  repair.  It  is  apt  also  to  induce  persistent  venous  oozing 
after  the  operation."  To  avoid  these  drawbacks,  he  employs  Gant's 
splint.  This  simple  splint,  instead  of  binding  the  femur  down  to  the 
level  of  the  tibia,  brings  the  tibia  up  to  the  level  of  the  femur,  and  no 
tight  bandaging  is  called  for. 

A  splint  which  answers  admirably  in  the  after-treatment  of  excision 
of  the  knee  is  Hodgens'  suspension  splint  (Fig.  124). 

Quite  a  number  of  the  splints  employed  have  the  disadvantage  of 
being  complex  and  difficult  to  adjust.  Dry  dressings  should  be  applied 
to  the  wound  and  should  not  be  changed  oftener  than  is  absolutely  neces- 
sary. If  silver  wires  are  used  to  maintain  the  bones  in  apposition,  they 
are  allowed  to  remain,  but  if  nails  have  been  used,  they  should  be 
removed  at  the  end  of  the  third  week.  The  dressings  should  not 
be  changed,  as  a  rule,  except  to  remove  the  drainage-tube.     The  limb 


400  POSTOPERATIVE    TREATMENT. 

must  be  kept  upon  the  splint  until  it  is  sound.  This  period  will  vary 
from  six  weeks  to  three  months.  Complete  recovery  can  usually  not 
be  expected  until  six  months  have  elapsed. 

After  the  splint  has  been  removed,  a  light  leather  support,  strength- 
ened with  a  strip  of  steel  at  the  back,  should  be  applied ;  and  in  the  case 
of  children  the  support  must  be  worn  for  two  or  three  years.  A  thick- 
soled  boot  will  be  required  to  meet  the  inevitable  shortening,  which, 
however,  in  the  most  favorable  cases,  does  not  amount  to  more  than 
about  an  inch. 


Fig.  124. 

Excision  of  Knee-joint  (Cheyne's  Method). — The  bleeding  is 
arrested  and  the  wound  stitched  up,  but  before  doing  so  it  is  well  to 
wire  the  femur  to  the  tibia ;  this  is  not  absolutely  essential,  but  it  keeps 
the  limb  in  position  while  the  dressings  are  being  applied,  and  it  serves 
to  prevent  any  antero-posterior  dislocation  of  the  bone  surfaces.  It 
must  be  remembered  that  the  divided  surface  of  the  tibia  is  much  broader 
than  that  of  the  femur,  and  if,  therefore,  the  anterior  margins  of  the 
two  bones  be  brought  into  apposition,  the  posterior  surface  of  the  tibia 
will  project  markedly  into  the  popliteal  space,  and  when  the  limb  is 


EXCISIONS    OR   RESECTIONS    OF   JOINTS. 


401 


placed  upon  the  splint,  pressure  may  be  exerted  ujjon  tJie  jjojjliteal 
artery,  aild  gangrene  of  the  limb  may  result.  The  posterior  margins 
of  the  bones  should  therefore  be  accurately  adjusted,  and  it  is  with  the 
view  of  securing  this  that  fixation  of  the  bones  is  advisable.  Some 
trouble  may,  however,  be  caused  from  the  extreme  softness  of  the  bone, 
which  allows  the  wires  or  pegs  to  cut  through  considerably,  and,  there- 
fore, great  care  must  be  taken  to  keep  the  limb  in  proper  positi(;n  after 
the  wire  has  been  introduced. 

As  a  rule,  it  is  well  to  introduce  a  drainage-tube  at  the  outer  edge 
of  the  incision,  the  rest  of  which  is  sewed  up  by  a  continuous  suture; 
the  limb  is  placed  upon  a  Thomas  knee  splint  (Fig.  123). 

Ajter-trealment. — ^When  a  drainage-tube  has 
been  used,  the  dressing  must   be  changed  in 
three   days,   at  which  time   the  tube  may  be 
removed.     When  changing  the  dressing  it  is 
well  to  have    a    fresh  splint   prepared   in   a 
manner  similar  to  the  original.     The  splint  is 
then  opened  and  the  front  of  the  knee  dressed; 
while  this  is  being  done,  an  assistant  must  fix 
the  thigh  to  prevent  starting  of  the  limb,  while 
another  similarly  fixes  the  leg.     It  is  well,  in 
fact,  at  the  first  dressing  to  keep  the  limb  in 
firm  contact  with  the   splint   by  opening  one 
side    at    a    time    while   the    limb   is    pressed 
against  the  other,  and  one  side  is  washed  and 
dressed  at  a  time.     The  splint  is  elevated,  the 
inclined  plane  or  pillow  upon  which  it  is  rest- 
ing is  removed,  and  then  the  splint  is  opened. 
One  assistant  grasps  the  thigh  and  another 
the  leg,  while  the  surgeon  grasps  the  limb  on 
either  side  of  the  knee;     the  splint  is   then 
allowed   to  drop  away  from  the  limb,  the  posterior  part  of  which  is 
thoroughly  washed  with  a  5  percent  carbolic  acid  solution  and  after- 
ward with  a  I  :  1000  mercuric  chlorid  solution.     The  fresh  splint,  with 
the  dressing   already  arranged,  is  put  in  place  beneath  the  limb  and 
gradually   raised   until  the   surgeon   and   the   assistants   can    remove 
their   hands   and  leave  the   limb  lying  upon  the   fresh   splint.     The 
strips  of  gauze  are  then  wrapped  around  th^  knee  and  the  dressing, 
and  the  splint  is  bandaged  on. 
27 


Fig.  125. 


402 


POSTOPERATIVE    TREATMENT. 


It  is  well  at  this  dressing  to  impregnate  the  outside  bandage  with  a 
starch  solution,  so  as  to  prevent  it  stretching  and  to  insure  that  the 
apparatus  will  keep  firm  for  six  weeks  or  so,  at  the  end  of  which  time 
it  may  be  taken  off,  the  stitches  removed,  and  the  limb  put  up  in 
plaster-of-paris  or  some  similar  immovable  apparatus. 

In  three  months  after  the  operation  union  is  usually  firm  enough  for 
the  patient  to  get  about  without  any  apparatus.  Massage  may  be  re- 
quired for  two  or  three  weeks  afterward  to  restore  the  circulation  and 
improve  the  nutrition  of  the  muscles. 

Excision  of  Ankle-joint. — Excision  of  the  ankle  is  now  seldom 
performed,  as  it  nearly  always  results  in  bony  ankylosis.  Arthrectomy 
of  the  joint  with  removal  of  the  astragalus  is  far  more  satisfactory  and 
leaves  the  patient  with  a  more  useful  limb. 


Fig.  126. — Volkmann's  Dorsal  Splint  for  Excision  of  the  Ankle. — {Da  Costa.) 


After-treatment  for  the  operation  is  as  follows :  The  dressings 
should  be  changed  in  a  fortnight,  when  the  wound  should  be  healed,  and 
the  stitches  may  be  removed.  The  limb  may  now  be  put  up  in  plaster- 
of-paris,  taking  care  to  keep  the  foot  strictly  in  its  normal  position.  The 
plaster  casing  should  be  maintained  for  about  six  weeks,  when  it  should 
be  renewed.  The  patient  should  not  be  allowed  to  walk  until  six  or 
eight  months  have  elapsed  from  the  time  of  the  operation. 

The  chief  trouble  after  arthrectomy  of  the  ankle  is  the  tendency  to 
lateral  deviation  of  the  foot, — more  particularly  inversion, — and  this 
must  be  carefully  guarded  against  by  the  use  of  apparatus  until  the  parts 
have  become  quite  firm.  Afterward  the  patient  must  wear  a  suitable 
boot  designed  to  prevent  lateral  displacement.  There  is  no  fear  of  the 
mobility  of  the  limb  becoming  impaired,  even  though  the  joint  be  kept 
in  plaster  for  six  months,  because  the  os  calcis  does  not  unite  firmly  to 
the  tibia  and  a  very  excellent  movable  joint  results. 


EXCISIONS   OR   RESECTIONS   OF   JOINTS.  4C3 

RESULTS  OF  EXCISION  OPERATIONS. 

The  advantages  claimed  for  the  subperiosteal  method  are  the 

following : 

{a)  The  periosteum  being  preserved,  new  bone  is  formed  to  replace 
that  which  has  been  removed. 

{h)  The  capsule  of  the  joint  is  preserved,  and  the  connections  of  the 
ligaments  are  not  severed;  the  new  articulation  is  therefore  likely  to  be 
all  the  stronger. 

(c)  The  connections  of  the  tendons  with  the  periosteum  are  not  dis- 
turbed, and  greater  muscular  strength  is  consequently  given  to  the  new 
joint. 

{d)  There  is  much  less  hemorrhage,  the  chief  area  of  the  operation 
being  subperiosteal. 

(e)  Planes  of  connective  tissue  are  not  opened  up,  and  the  cavity 
left  after  the  removal  of  the  bones  is  limited  and  circumscribed  by  the 
capsuloperiosteal  sheath. 

With  regard  to  these  claims,  there  is  no  doubt  that,  in  favorable 
circumstances,  a  large  quantity  of  new  bone  is  produced  to  make  good 
that  lost  by  the  operation.  The  importance  of  the  periosteum  in  this 
connection  would  appear  to  be  paramount,  although  some  recent  writers 
have  adduced  evidence  in  support  of  the  view  that  the  bone-forming 
functions  of  the  periosteum  have  been  overestimated. 

In  the  most  successful  cases  it  cannot  be  said  that  the  articular  ends 
of  the  bone  are  reproduced,  and  that  the  new  joint  is  a  reproduction  of 
the  old.  New  bone  is  formed,  and  fills,  in  part,  the  periosteal  ca^'ity, 
and  by  the  periosteum  it  is  limited  and  molded.  The  new  bone  is,  as  it 
were,  poured  into  a  mold.  The  amount  produced  varies.  In  some 
instances  no  new  bone  is  produced,  even  when  a  considerable  portion 
of  the  periosteum  is  saved ;  in  other  cases  an  excessive  amount  is  found 
to  have  been  formed;  in  a  few  examples  the  reproduction  of  the  details 
of  the  lost  bones  has  been  precise  and  remarkable.  In  all  circumstances 
it  would  appear  that  the  new  bone  is  a  little  unstable,  and  that  it  is  liable 
to  undergo  a  certain  but  varying  amount  of  resorption. 

The  value  of  the  new  bone  so  produced  cannot  be  overestimated 
when  the  results  of  operations  come  to  be  compared,  and  the  main 
advantage  of  the  subperiosteal  method  may  be  considered  to  be  based 
upon  this  feature.  The  preservation  of  ligaments  and  tendinous  con- 
nections is  another  advantage  of  this  method — an  advantage  that  is 
substantial  and  definite. 


404 


POSTOPERATIVE    TREATMENT. 


The  disadvantages  of  the  subperiosteal  operation  cannot,  on  the 
other  hand,  be  overlooked.  The  measure  is  admirable  in  theory,  but  it 
does  not  always  assume  so  immaculate  a  position  in  practice.  In  the 
first  place,  the  operation  is  often  impossible.  The  detachment  of  the 
periosteum  is  difficult  and  tedious.  In  traumatic  cases,  in  adults,  the 
surgeon  will  find  in  practice  that  the  strict  carrying  out  of  the  method  of 
Oilier  is  barely  possible. 

The  operator  who  blindly  persists  in  following  this  method  will  often 
find  that,  after  much  valuable  time  has  been  exhausted,  he  has  bared  the 

bone  of  periosteum,  but  has  left  that  mem- 
brane in  shreds  and  holes.  In  young  sub- 
jects the  periosteum  is  thicker,  more  active, 
more  substantial,  and  more  easily  stripped 
ofi".  It  may  also  be  said  that  it  is  more 
precious,  and  is  in  more  need  of  being  pre- 
served. 

In  cases  attended  by  chronic  inflamma- 
tion the  periosteum  is  generally  very  easily 
detached,  but  in  such  a  condition  it  is  often 
of  doubtful  value.  It  may  be  infiltrated 
with  inflammatory  or  tuberculous  material, 
may  hinder  the  healing  of  the  wound,  and 
may  even  maintain  suppuration.  But  if  it 
lack  these  potentialities  for  evil,  it  may  pos- 
sess no  bone-producing  property. 

In  the  next  place,  the  subperiosteal  oper- 
ation involves  a  considerable  period  of  time 
in  the  performance,  and  the  shock  follow- 
ing   the    procedure    may    be  considerable. 
In  this  respect  it  compares  unfavorably  with  an  excision  by  the  open 
method,  where  the  actual  steps  of  the  operation  are  simple  and  the 
process  quick. 

The  open  method,  practised  as  it  was  in  the  earher  days  of  surgery, 
when  ligaments  and  tendons  were  divided  without  scruple,  may  be 
safely  regarded  as  a  matter  of  the  past ;  but  such  a  modification  of  this 
method  as  the  subperiosteal  procedure  suggests  is  of  great  value. 

Summary. — So  far  as  excisions  of  joints  are  concerned,  the  con- 
ditions that  may  be  considered  under  this  heading  are  very  numerous 
and  can  only  be  dealt  with  in  outhne.  They  concern  not  only  those 
general  circumstances  that  influence  the  healing  of  wound  and  the  re- 


FiG.  127. — Bone  Denuded  OF 
Periosteum  Result  of 
Chronic  Inflammation. 


EXCISIONS   OR   RESECTIONS   OF   JOINTS.  405 

covery  of  patients  after  operation,  Ijut  embrace  certain  local  features 
that  are  more  or  less  obvious. 

The  success  of  the  operation  will  depend  upon  the  age  of  the  pa- 
tient, upon  his  condition,  upon  his  powers  of  exhibiting  repair  from 
extensive  wounds,  and  upon  the  general  circumstances  that  affect  pri- 
mary healing.  His  nervous  condition  is  a  matter  of  importance,  as  is  also 
his  capacity  for  submitting  to  tedious  and  often  painful  after-treatment. 
The  question  of  perfect  asepsis  needs  but  to  be  mentioned.  So  far  as 
the  operation  is  concerned,  much  will  depend  upon  the  state  of  the  tis- 
sues, upon  the  nature  of  the  disease,  upon  the  amount  of  bone  removed, 
upon  the  complete  "elimination  of  the  morbid  structures,  and  upon  the 
safety  of  important  tissues  in  the  vicinity  of  the  operation. 

Few  operations  can  be  cited  in  which  the  after-treatment  is  more 
important,  and  in  which  it  has  a  greater  influence  upon  the  success  of 
the  case.  However  well  the  excision  may  have  been  carried  out,  and 
however  favorable  the  case  may  be,  the  whole  complexion  may  be  altered 
and  transformed  by  neglect  in  the  after-treatment. 

The  wound  must  be  kept  aseptic,  and  in  general  terms  it  may  be 
said  that  dry  and  infrequent  dressings  should  be  mainly  relied  upon. 
The  splint  must  be  selected  with  care,  and  must  be  applied  with  pre-, 
cision.  The  principal  features  in  the  after-treatment  are  identical  with 
those  attending  the  care  of  compound  fractures. 

The  position  of  the  limb  must  be  accurately  prescribed.  If  anky- 
losis is  wished  for,  the  bones  must  be  brought  into  close  contact,  and 
must  be  kept  in  very  rigid  relation  to  one  another.  If  it  be  intended 
that  a  movable  articulation  shall  result,  then  the  approximation  of  the 
bones  should  be  less  close.  No  rule  can  be  given  that  will  render 
definite  the  precise  degree  of  separation  of  parts  that  is  desirable  after 
the  operation.  The  approximation  will  be  less  close  in  adults  than 
in  young  subjects,  and  in  cases  in  which  much  periosteum  has  been 
preserved  than  in  those  where  much  has  been  lost.  It  may  be  that  a 
week  or  so  will  have  to  elapse  before  the  surgeon  can  satisfy  himself 
that  the  adjustment  of  the  sawed  ends  of  the  bones  is  the  best  that  can 
be  attained. 

Skiagraphy  is  very  useful  in  determining  the  treatment  of  excision. 
In  some  instances,  notably  those  associated  with  existing  deformity 
of  the  joint,  it  may  not  be  wise  to  enforce  the  ideal  position  at  once, 
but  the  limb  will  have  to  be  brought  gradually  into  the  desired  attitude. 

When  mobihty  is  desired,  passive  motion  will  have  to  be  under- 


4o6  POSTOPERATIVE    TREATMENT. 

taken.  This  may  be  commenced  so  soon  as  the  inflammatory  symp- 
toms have  subsided,  and  so  soon  as  the  sensitiveness  of  the  part  has 
become  less  acute.  In  most  cases  this  will  be  represented  by  a  period 
varying  from  o,ne  to  three  weeks.  Passive  motion  should  not  be  begun 
until  the  operation  wound  has  soundly  healed.  The  treatment  of  the 
general  health,  the  duration  of  the  treatment  by  apparatus,  and  the 
employment  of  massage  and  electricity  will  depend  upon  general 
principles. 


CHAPTER  XVIII. 

OSTEOMYELITIS,   OPERATIONS    FOR    CLUB- 
FOOT, OSTEOTOMY  FOR  GENU 
VALGUM,  ETC. 


CHAPTER  XVIII. 

OSTEOMYELITIS,  OPERATIONS  FOR  CLUB-FOOT,  OSTEOT- 
OMY FOR  GENU  VALGUM,  ETC, 

OSTEOMYELITIS. 

New  Method  of  Postoperative  Treatment  of  Chronic  Osteomye- 
litis.— (Abstract  from  article  by  Dr.  E.  H.  Nichols,  Boston,  ]\Iass., 
"Am.  Med.  Jour.") 

The  operation  consists  of  an  incision  through  skin  and  ossified 
periosteum  down  to  necrotic  shaft,  reflection  of  the  periosteum,  removal 
of  the  shaft,  either  entire  or  partial,  folding  of  the  plastic  periosteum 
in  such  a  way  as  to  approximate  the  internal  layers,  suture  of  the  edges 
by  absorbable  sutures,  suture  of  the  soft  tissues,  with,  in  both  cases, 
provision  for  moderate  drainage  and  complete  immobilization.  After 
removal  of  the  necrotic  shaft  well-marked  ossification  of  the  new  peri- 
osteal shaft  appears  between  the  twentieth  and  fortieth  days,  and  the 
shaft  is  solid  enough  for  use  in  locomotion  in  from  four  to  eight  months. 
If  the  epiphyseal  line  is  extensively  destroyed,  considerable  shortening 
of  the  limb  may  result. 

This  is  the  operation  of  preference,  and  is  especially  applicable  when 
an  accessory  bone  which  can  act  as  a  splint  is  present.  The  best  time 
for  the  operation  ordinarily  is  about  two  months  after  complete  drainage 
of  the  acute  infection. 

The  anatomic,  functional,  and  cosmetic  results  obtained  by  this 
operation  are  much  superior  to  those  obtained  in  any  other  w^ay  in  cases 
of  large  bony  defects  due  to  acute  infection  of  bone. 

The  chief  difficulty  in  completing  the  restoration  of  the  shaft  is  to 
obtain  complete  union  of  the  regenerated  shaft  to  the  epiphyseal  line 
or  to  the  portion  of  the  normal  shaft  that  remains.  Slight  necrosis 
and  suppuration  may  persist  at  this  point  after  the  repair  otherA^ise  is 
complete,  and  may  demand  minor  operations  to  remove  small  frag- 
ments of  necrotic  bone.  Union  at  these  points  may  be  delayed,  but 
ultimately  always  has  taken  place.  When  no  accessory  splint  is  present, 
it  may  be  impossible,  in  special  cases,  to  maintain  the  contour  of  the 

409 


4IO 


POSTOPERATIVE    TREATMENT. 


affected  bone  by  the  above-mentioned  method.  In  such  cases  advan- 
tage can  be  taken  of  the  power  of  central  growth  possessed  by  the  shell 
of  periosteal  bone  in  its  early  stages.  This  means  that  the  necrotic 
bone  must  be  removed  just  as  soon  as  the  periosteal  shell  is  sufficiently 
advanced  and  solid  to  maintain  contour  and  bear  the  weight  of  the  limb. 
Roughly,  this  stage  is  reached  when  the  thickness  of  the  periosteal  shell 
is  equal  to  one-fourth  of  the  diameter  of  the  original  shaft.     The  time 


Fig.  128. — Recovery  after  Partial  Re- 
section OF  Humerus. — (Nichols.) 


Fig. 


129. — Recovery  from  Chronic 
Osteomyelitis. — (Nichols.) 


when  this  condition  exists  can  be  determined  by  Rontgen-ray  exami- 
nation and  by  palpation. 

If  the  necrotic  shaft  is  removed  at  this  time,  it  leaves  a  solid  cylinder 
of  periosteal  bone,  very  vascular,  but  partly  calcified,  analogous  to  the 
bone  seen  in  an  early  external  callus,  and  this  shell  has  sufficient  power 
of  central  growth  to  fill  up  large  cavities.  The  rate  of  central  growth 
seems  to  be  markedly  slower  than  that  of  peripheral  growth.  Persis- 
tence of  sinuses  is  longer  than  in  the  preceding  method,  partly  from  a 


OSTEOMYELITIS.  4I I 

failure  to  remove  small  fragments  of  necrotic  bone  at  the  time  of  opera- 
tion. 

Finally,  the  most  satisfactory  results  in  treatment  of  acute  osteo- 
myelitis can  be  obtained  by  complete  drainage  of  soft  tissues  and  marrow 
in  the  acute  stage,  with  the  removal  of  extensive  necroses,  if  they  fjccur, 
at  a  secondary  operation  undertaken  about  two  months  later,  and  by 
adaptation  of  the  regenerative  power  of  the  periosteum  for  the  forma- 
tion of  a  new  shaft. 

After-treatment. — Certain  precautions  and  difficulties  in  the 
operation  and  after-treatment  should  be  considered.  Of  course,  some 
infection  and  suppuration  will  be  present  when  the  operation  is  done, 
but  they  should  be  minimized  as  far  as  possible.  For  this  purpose 
free  incisions,  followed  by  careful  daily  dressing  and  irrigation,  should 
be  provided  for  some  time  before  removal  of  the  shaft  when  necessary. 
Often  the  reaction  to  the  inflammatory  process  in  the  soft  tissues  and 
periosteum  leads  to  the  formation  of  an  enormous  amount  of  vascular 
granulation  tissue  in  the  soft  parts  about  the  bone.  Incision  of  such 
parts  may  lead  to  great  oozing  hemorrhage  during  the  operation,  suf- 
ficient at  times  to  make  the  operation  dangerous  from  loss  of  blood. 
This  may  be  avoided  by  the  application  of  an  Esmarch  bandage  before 
the  operation  and  removal  after  the  dressing.  I  have  known  of  two 
cases  where  the  hemorrhage  was  so  severe  as  to  require  that  the  opera- 
tion be  done  in  two  steps :  at  the  first  step  periosteum  was  partly  peeled 
back  from  the  bone  and  the  operation  completed  some  days  later  after 
hemorrhage  had  ceased. 

In  regard  to  closing  the  wound,  it  is  to  be  remembered  that  the  opera- 
tion practically  never  is  done  on  perfectly  aseptic  tissues.  Some  sup- 
puration may  take  place  between  the  approximated  surfaces  of  perios- 
teum, and  some  is  sure  to  take  place  between  the  soft  tissue  edges.  Con- 
sequently it  is  advisable  to  leave  the  stitches  in  the  periosteum  as  far 
apart  as  is  possible  with  accurate  approximation  of  the  edges.  The  edges 
of  the  soft  tissue  may  be  closely  approximated,  but  provision  for  drain- 
age should  be  made  by  very  small  gauze  wicks  or  catgut  drains. 

The  operation  produces  moderate  depression,  not  so  severe  as  an 
amputation.  In  spite  of  all  precautions  there  is  likely  to  be  some 
evidence  of  septic  absorption,  which  makes  its  appearance  on  the  second 
or  third  day,  but  usually  disappearing  within  a  week.  In  two  cases 
the  post-operative  infection  w^as  sufficient  to  cause  mild  delirium  for 
several  days. 


412  POSTOPEEATIVE    TREATMENT. 

The  wound  may  heal  by  first  intention  over  the  greater  portion,  but 


Fig.  130. — Marked  Induration  of  Tibia. — (Nichols.) 
some  redness  and  sKght  sloughing  of  the  edges  may  appear.     In  one 


OSTEOMYELITIS.  413 

case  this  sloughing  was  sufficient  to  cause  considerable  gaping  both  of 
soft  tissue  and  periosteum.  Sinuses  often  develop  for  a  time,  but  have 
always  ultimately  disappeared.  They  usually  appear  near  the  epiphy- 
sis, or  at  the  junction  of  periosteum  and  shaft.  As  has  been  said,  some- 
times a  slight  amount  of  cureting  may  be  necessary  before  permanent 
closure  takes  place.  It  is  desirable  to  prevent  retention  of  infected 
material  because  of  danger  to  the  epiphysis  and  ultimate  infection  of 
the  joint. 

The  first  dressing  should  be  changed  by  the  third  day.  After  that 
time,  dressings  should  be  replaced  sufficiently  often  to  absorb  any  dis- 
charge; a  wet  dressing  may  be  necessary  for  the  first  ten  days. 

Marked  induration  along  the  line  of  the  bone  is  f recjuently  felt  by  the 
third  week  (Fig.  130.)  From  that  time  on  the  bone  gradually  increases 
in  density  and  size.  The  new  shaft  at  first  and  for  some  months  has  no 
marrow  canal,  but  is  composed  entirely  of  trabeculae  from  periosteal  bone 
with  granulation  tissue,  instead  of  fat-marrow.  The  new  shaft  grows 
to  be  larger  than  the  original  shaft  during  the  early  months,  but  in  time 
decreases  in  size  and  practically  comes  to  the  size  of  the  corresponding 
shaft.  In  course  of  time  a  marrow  canal  appears  in  the  new  bone,  to 
judge  from  the  Rontgen-ray  pictures.  As  a  rule,  the  new  shaft  is  a  trifle 
more  irregular  than  the  original  shaft.  The  shaft  is  strong  enough 
to  allow  free  use  after  from  five  to  eight  months.  Even  when  the  entire 
diaphysis  has  been  removed,  if  the  epiphyseal  line  has  not  been  inter- 
fered with,  no  shortening  of  the  limb  need  result,  and  that,  too,  in  young 
adults  of  fourteen  years.  As  far  as  function  and  use  go,  the  results 
often  are  absolutely  perfect.  Even  in  cases  in  which  the  epiphysis  is 
interfered  with,  the  shortening  may  be  slight  and  the  function  perfect. 


CLUB-FOOT. 

As  to  Bandaging. — When  a  deformed  foot  has  been  corrected 
surgically,  the  first  stage  only  of  the  treatment  may  be  said  to  have  been 
accomplished.  The  foot  must  then  be  fixed  by  plaster  bandages  in  an 
overcorrected  position.  It  is  first  evenly  covered  with  a  layer  of  cotton, 
and  a  broad  bandage  of  canton  flannel,  after  which  the  plaster  band- 
ages are  applied  from  the  tips  of  the  toes  to  the  upper  part  of  the  thigh. 
It  is  important  that  the  toes  should  not  project  beyond  the  bandage, 
because  of  the  swelling  that  sometimes  follows.  It  is  important,  also, 
that  the  foot  should  be  held  in  the  proper  position  while  the  bandage 


414 


POSTOPERATIVE   TREATMENT. 


is  hardening,  and  that  it  should  not  be  manipulated  to  any  extent  after 
the  bandage  is  applied,  in  order  that  no  rigid  wrinkle  may  press  against 
the  skin.  The  bandage  is  carried  above  the  knee  in  order  that  the 
tibia  may  be  rotated  outward  to  its  normal  position  and  held  there,  and 
because  more  effective  fixation  can  be  assured  and  greater  pressure 
exerted  on  the  foot  in  walking.  To  utilize  this  pressure  to  better  ad- 
vantage the  bandage  should  be  made  very  thick  beneath  the  sole,  and  a 
thin  foot-plate  of  wood  should  be  incorporated  in  the  plaster.  When 
the  bandage  is  applied,  the  position  of  the  foot  should  be  that  of  over- 
correction of  deformity,  flexed  beyond  a  right  angle,  twisted  far  out- 
ward, and  the  outer  border  should 
be  elevated  considerably  beyond 
the  level  of  the  inner  border. 

One  would  suppose,  after  using 
the  force  that  has  been  necessarily 
applied,  that  much  pain  and  swell- 
ing would  follow.  This  is,  how- 
ever, not  the  case.  Often,  on  the 
following  day,  the  patients  are  able 
to  stand  upon  the  foot,  and  always 
within  the  first  week  if  the  bandage 
has  been  properly  applied.  The 
pain  following  this  operation  is  far 
more  often  caused  by  pressure  of 
an  ill-fitting  bandage  than  by  the 
violence  that  has  been  used.  Thus 
one  should  be  careful  to  remove 
sections  of  the  bandage  if  it  appears 
to  cause  undue  discomfort.  The 
points  of  discomfort  are  usually  the  front  of  the  ankle,  the  back  of  the 
heel,  and  the  inner  border  of  the  great  toe. 

The  first  bandage  should  be  removed  at  the  end  of  about  three  weeks, 
as  it  will  have  become  loose.  The  foot  will  then  be  found  to  be  ex- 
tremely flexible,  and  by  an  enthusiast  it  might  be  considered  cured. 
But  knowledge  of  its  previous  condition  should  make  it  evident  that 
a  much  longer  time  will  be  required  for  its  consolidation  in  the  new 
position.  At  this  time  almost  no  evidence  of  the  operation  remains, 
except,  it  may  be,  slight  discoloration  of  the  skin.  The  foot  is  again 
held  as  far  as  possible  in  the  overcorrected  position  and  another  plaster 


Fig.  131. — Attitude  of  Overcorrec- 
tion IN  which  the  Feet  are 
Fixed  after  the  Operative 
Treatment. — {Whitman.) 


CLUB-FOOT. 


415 


bandage  is  applied,  usually  as  far  as  the  knee  only.  'J'his  remains  for 
four  weeks,  or  longer  if  it  is  still  unbroken.  The  patient  uses  the  foot 
constantly,  and  is  drilled  in  the  proper  method  of  walking,  so  that  the 
muscles  of  the  leg  may  become  accustomed  to  the  new  and  normal  atti- 
tudes. This  second  bandage  is  allowed  to  remain  frrjm  four  to  six 
weeks. 

In  some  instances  the  deformity  is  now  actually  cured,  but  in  the 
great  majority  of  cases,  while  the  foot  may  be  normal  in  appearance, 
its  muscular  balance  has  not  been  restored.     If,  at  this  stage,  treat- 


w/-  /^^-^^i 


Fig.  132. — -Taylor  Club-foot  BRACE.^{]]'liitmaii.) 


ment  be  abandoned,  the  deformity  w^ill  invariably  recur.  The  foot 
should  be  supported  in  the  proper  position,  aided  by  massage  and 
stimulation  of  the  muscles,  until  the  child  has  been  able  to  walk  firmly 
upon  it. 

The  Retention  Brace. — The  form  of  retention  brace  will  var}- 
somewhat  according  to  the  indications  of  the  individual  case.  The 
best  and  simplest  support  is  the  Taylor  brace,  the  invention  of  Dr.  C.  F. 
Taylor,  of  New  York.     (Figs.  133,  134.) 

This  consists  essentially  of  a  light  upright  that  extends  along  the 


4i6 


POSTOPERATIVE    TREATMENT. 


inner  side  of  the  leg  to  the  knee,  and  a  thin  steel  foot-plate,  the  exact 
size  of  the  sole,  with  an  upright  flange  on  the  inner  side,  rising  to  a  point 
just  above  the  dorsal  surface  of  the  foot,  against  which  the  foot  is  pressed 
closely  so  that  recurrence  of  the  varus  deformity  is  prevented.  The 
joint  at  the  ankle  is  provided  with  a  catch  that  prevents  plantar  flexion, 
but  allows  dorsal  flexion.  By  bending  the  upright  and  the  sole-plate, 
the  foot  may  be  held  in  slight  abduction  and  e version.  The  apparatus 
is  applied  with  straps,  as  illustrated,  and  if  necessary,  its  position  is 
further  fixed  by  a  band  of  adhesive  plaster,  applied  on  the  inner  side  of 
the  leg  to  hold  the  heel  firmly  against  the  foot-plate.  The  foot  is  thus 
held  constantly  at  a  right  angle  to  the  leg,  or,  better,  in  the  early  stage  of 


Fig.  133.  Fig.  134- 

Taylor  club-foot  brace,  showing  method  of  application  and  attachment. — {Whitman.) 


treatment,  in  an  attitude  of  dorsal  flexion  and  valgus.  Occasionally 
after  complete  rectification  of  the  deformity,  the  foot  still  turns  in.  In 
most  instances  this  is  due  to  an  inward  rotation  of  the  tibia  on  the  femur 
at  the  knee-joint,  but  in  some  cases  it  is  caused  by  a  spiral  twist  of  the 
tibia  itself. 

In  order  to  correct  this  secondary  deformity  an  extension  of  the 
upright  of  the  brace  is  carried  beneath  the  leg,  provided  with  a  joint  at 
the  knee,  and  is  extended  up  the  outer  side  of  the  thigh.  At  the  hip  it  is 
attached  by  a  free  joint  to  a  padded  pelvic  band  of  light  steel.  The  band 
holds  the  upright  in  the  proper  relation  to  the  thigh;   thus,  by  twisting 


CLUB-FOOT. 


417 


the  part  below  the  knee  the  foot  can  be  rotated  outward  to  the  desired 
degree.  In  less  marked  cases  the  retention  bands  used  for  pigeon-toe 
may  be  employed. 

Methodical  Manual  Correction. — Several  times  during  the  day 
the  brace  should  be  removed  in  order  that  the  foot  may  be  thoroughly 
massaged  and  forcibly  turned,  first  toward  valgus,  that  is,  outward  at 
the  mediotarsal  joint  so  that  the  inner  border  is  made  convex,  and  then 
to  the  extreme  Hmit  of  dorsal  flexion  and  abduction.  If  the  leg  is  rotated 
inward,  it  is  forcibly  rotated  outward  on  the  femur.  Even  if  the  tibia  is 
actually  twisted  on  its  long  axis,  the  influence  of  the  brace  and  forcible 


Fig.  135.  Fig.  136. 

Taylor  club-foot  brace,  showing  adhesive  plaster,  by  means  of  which  the  heel  is  held 

down,  and  the  method  of  attachment. —  (Whitman.) 


manipulation  will  usually  correct  the  deformity.  Active  contraction  of 
the  weak  muscles  may  be  induced  by  tickling  the  sole  of  the  foot  or  by 
the  use  of  electricity;  and,  finally,  the  entire  limb  should  be  thoroughly 
massaged  before  the  brace  is  reapplied. 

When  the  deformity  shows  no  tendency  to  recur,  the  brace  may  be 
removed  for  a  part  of  the  day;  later  it  is  used  only  at  night,  and  finally  it 
may  be  discarded  if  the  child  walks  normally.  But  it  is  best  to  continue 
the  daily  manipulation,  more  particularly  the  systematic  stretching  or 
overcorrection  of  the  foot,  for  a  long  time.  Thus  one  may  assure  one's 
28 


4l8  POSTOPERATIVE    TREATMENT. 

self  that  there  is  no  tendency  toward  deformity,  of  which  the  first  symp- 
tom is  always  a  slight  limitation  of  the  range  of  dorsal  flexion  and  of 
abduction. 

In  some  instances  the  deformity  may  have  been  so  thoroughly  over- 
corrected  by  the  plaster-of-paris  bandage  or  by  the  brace,  and  the  after- 
treatment  of  massage  and  stretching  may  have  been  so  efficiently  applied 
by  the  nurse  or  parent,  that  the  retention  brace  may  be  unnecessary. 

On  the  other  hand,  the  inclination  toward  deformity  may  be  so 
marked  that  a  brace  may  be  necessary  to  hold  the  foot  in  slight  abduction 
and  valgus  for  a  year  or  longer.  In  other  cases  the  use  of  a  light  brace 
to  hold  the  foot  in  the  overcorrected  position  during  the  night  is  alone 
required.  These  are  points  to  be  decided  by  the  circumstances  in  the 
case.  The  period  of  observation  and  supervision  is  included  in  the  final 
stage  of  the  treatment. 

During  this  period  the  attitudes  of  the  limb  and  foot  of  the  walking 
child  must  be  carefully  watched,  and  particularly  the  signs  of  wear  on  the 
sole  of  the  shoe.  If  it  shows  greater  wear  on  the  outer  side  than  is  usual, 
it  is  an  indication  that  the  weight  does  not  fall  directly  on  the  center  of 
the  foot,  but  to  the  outer  side,  and  that  there  is  therefore  a  tendency 
toward  deformity.  This  must  be  counteracted  by  making  the  sole 
thicker  on  the  outer  side,  or  slightly  wedge-shaped,  so  that  the  weight 
may  be  deflected  toward  the  inner  border. 

This  third  period  of  treatment,  or  rather  of  oversight  of  the  func- 
tional use  of  the  foot,  must  be  continued  indefinitely.  In  fact,  it  is  the 
quality  of  this  final  supervision  that  decides  in  most  instances  whether  the 
ultimate  outcome  is  to  be  what  is  called  a  satisfactory  result,  or  a  perfect  cure. 


TALIPES    CALCANEUS. 

After-treatment. — Whatever  surgical  method  be  adopted,  care 
must  be  taken  to  keep  the  foot  in  a  position  of  somewhat  marked  equinus 
for  at  least  six  or  eight  weeks,  so  as  to  permit  sound  union  between  the 
divided  ends  of  the  tendon;  even  after  this  time  great  care  has  to  be 
exercised  not  to  put  strain  on  it  for  fear  of  stretching  the  uniting  structure. 
The  patient  should  not  be  allowed  to  walk  about  to  any  extent  for  at 
least  six  months  after  the  operation.  When  walking  is  permitted,  he 
should  be  furnished  with  the  apparatus  here  described.  This  consists 
of  the  lateral  irons  fitted  into  a  surgical  boot  with  a  stop  which  pre- 
vents the  joint  being  flexed  beyond  a  right  angle.     From  six  weeks 


TALIPES   CALCANEUS.  419 

after  the  operation  the  calf  slioulcl  ];c  thoroughly  massaged  and 
douched  once  or  twice  daily,  and  the  farach'c  current  ;i];p!icfl  to  tlic 
muscle. 

Transplantation  of  Tendo  Achillis. — The  other  plan  sometimes 
employed  is  not  to  divide  the  tendon  at  all,  on  account  of  the  rianger  of 
subsequently  stretching  the  uniting  tissue,  but  to  alter  the  bony  attach- 
ment of  the  tendo  Achillis  to  the  os  calcis.  When,  owing  to  paralysis, 
the  nutrition  of  the  leg  is  faulty,  and  when,  therefore,  the  union  in  such 
a  slightly  vascular  structure  as  tendon  will  very  probably  be  extremely 
imperfect,  there  is  no  doubt  that  a  more  satisfactory  result  w'ill  be 
obtained  by  altering  the  point  of  insertion  of  the  tendo  Achillis  into  the 
OS  calcis.  The  great  objection  to  this  plan  is,  however,  that  the  amount 
of  shortening  obtained  by  its  means  is  comparatively  limited,  and  the 
method  is  of  real  value  only  when  the  deformity  due  to  talipes  calcaneus 
is  very  moderate. 

Two  operations  have  been  recommended;  in  the  first  a  flap  with  its 
convexity  upward  is  raised  over  the  heel,  and  dissected  dovniward  so  as 
to  expose  the  whole  of  the  posterior  part  of  the  os  calcis.  A  saw  is  then 
applied  to  the  upper  surface  of  the  bone  immediately  in  front  of  the 
tendon,  and,  by  a  vertical  cut,  a  thin  slice  of  the  bone,  with  the  attached 
tendo  AchilHs,  is  sawed  off.  This  slice  of  bone  is  pulled  down  until  the 
insertion  of  the  tendon  is  at  a  point  as  low  as  may  be  necessarv^,  or  as  low 
as  possible,  and  the  bone  is  fixed  into  its  new  position  by  two  or  three 
small  screws  or  nails.  The  projecting  lower  portion  of  the  slice  of  bone 
is  then  cut  off  so  as  to  make  it  level  with  the  under  surface  of  the  os  calcis. 

In  some  cases  in  which  the  tendon  is  very  long  it  has  been  advised 
that  the  upper  part  of  the  bone  thus  sawed  off  should  be  turned  round  at 
a  right  angle  and  applied  to  a  raw  surface  made  by  cutting  off  sufi&cient 
of  the  under  surface  of  the  os  calcis;  this  is  done  to  bring  down  the 
insertion  of  the  tendon  to  the  lowest  possible  point.  The  results  of 
attempts  to  produce  great  shortening  in  this  manner  do  not,  however, 
seem  to  be  very  satisfactory. 

After-treatment. — After  the  operation  the  wound  is  stitched  up 
without  a  drainage-tube,  the  usual  antiseptic  dressings  are  applied,  and 
the  foot  is  put  upon  a  splint  so  that  the  toes  are  markedly  pointed,  and 
are  kept  in  that  position  for  about  six  weeks,  until  bony  union  is  com- 
plete. After  that  time  the  patient  may  be  allowed  to  walk  about  with 
the  boot  alreadv  described. 


420 


POSTOPERATIVE    TREATMENT. 


OSTEOTOMY  FOR  CURVED  TIBIA  AND  FIBULA. 

After-treatment. — According  to  Cheyne-Burghard,  the  limb  should 
be  put  on  a  splint,  and  for  this  purpose  we  generally  employ  a  trough 
of  Gooch's  or' Day's  veneer  flannel  or  kid-lined  splinting,  for  the  first 
few  days,  until  the  wound  has  healed  and  the  stitches  are  removed. 
This  trough  is  cut  of  sufficient  breadth  to  surround  rather  more  than 
half  the  limb,  and  to  extend  from  the  fold  of  the  buttock,  where  it  is 
cut  away  obliquely  from  within  outward  and  upward,  to  well  below 


Fig.  137. — Dr.  Chas.  F.  Stillman's  Long  Bow-leg  Brace. 


the  foot.  A  portion  of  the  splint  should  be  cut  out  opposite  the  heel 
so  that  no  injurious  pressure  shall  be  exerted,  but  in  quite  small  children 
this  need  not  be  done ;  instead,  the  padding  may  be  so  arranged  that  the 
heel  is  pushed  somewhat  forward  and  at  the  same  time  does  not  press 
upon  the  splint.  The  limb  is  made  to  fit  the  splint  exactly  by  means 
of  a  number  of  pads  of  suitable  size  and  shape,  packed  in  on  each  side 
and  below  the  limb,  which  may  thus  be  fixed  in  any  position  that  is 
most  suitable.  It  is  well  to  place  a  special  pad  over  the  front  of  the 
knee  and  leg,  and  by  graduating  the  padding  any  desired  amount  of 
inversion  or  eversion  of  the  foot  can  be  obtained;   generally  speaking. 


OSTEOTOMY   FOR  GENU   VALGUM.  42 1 

a  large,  long  pad  should  ])c  applied  opposite  the  jjoint  of  greatest 
convexity  of  the  curve  that  it  is  required  to  obhterate,  and  smaller, 
thicker  ones  between  the  ends  of  the  bones  and  the  side  of  the  splint. 
The  latter  is  then  fastened  round  the  limb  by  broad  bandages,  and  the 
whole  is  laid  upon  an  inclined  plane,  to  which  it  may  be  secured  by  one 
or  two  strips  of  bandage. 

In  about  a  week  or  ten  days  the  splint  may  be  undone,  the  stitches 
removed,  and  a  collodion  dressing  apphcd.  Any  additional  correction  of 
the  deformity  may  then  be  made,  if  necessary,  under  an  anesthetic, 
and  the  limb  put  up  in  the  fully  rectified  position  in  a  plaster-of-paris 
or  silicate  of  potash  bandage  and  left  for  about  six  weeks  for  union  to 
occur;  it  is,  of  course,  necessary  that  the  foot  should  be  strictly  at  a 
right  angle.  In  six  weeks'  time  the  old  bandage  may  be  taken  off  and 
a  fresh  one  applied  for  a  similar  period,  when  the  union  should  be  thor- 
oughly firm,  after  which  a  Stillman's  long  or  short  brace  should  now 
be  applied  and  worn  for  several  months  (see  Fig.  137). 

This  apparatus  exerts  a  constant  spring  force,  which  tends  to  over- 
come or  prevent  deformity.  It  is  adjustable  by  means  of  rachets  and 
a  key,  and  is  very  effective,  for  not  only  does  it  support  the  limb  while 
the  deformity  is  being  reduced,  but  the  rachets  at  the  lower  extremity 
of  the  instrument  allow  the  surgeon  to  control  the  position  of  the  feet 
at  the  same  time. 

The  short  brace  is  worn  only  below  the  knee,  and  is  intended  merely 
for  cases  in  which  the  curvature  is  slight  or  entirely  below 'the  knee. 


OSTEOTOMY  FOR  GENU  VALGUM. 

After-treatment.^Cheyne  states  that  after  the  completion  of  the 
operation  one  or  two  sutures  should  be  inserted,  an  antiseptic  dressing 
applied,  the  limb  brought  straight  and  put  upon  a  suitable  sphnt,  which 
we  are  accustomed  to  make  from  a  roll  of  Gooch's  or  Day's  splinting 
properly  padded.  If  an  ordinar}^  straight  splint  is  used,  it  is  well  to 
cut  away  a  space  for  the  heel  so  as  to  obviate  all  fear  of  pressure  upon 
the  OS  calcis.  In  applying  the  padding  special  care  must  be  taken  to 
have  a  large  pad  over  the  internal  condyle,  and  others  over  the  outer 
side  of  the  foot  and  ankle,  so  as  to  press  the  leg  inward  and  keep  it 
in  good  position.  Another  special  pad  must  be  placed  in  front  of  the 
knee  so  as  to  prevent  flexion  at  the  joint. 

After  the  spHnt  has  been  apphed  the  Hmb  should  be  laid  upon  an 
inclined  plane.     In  about  a  week  or  ten  days  the  dressing  may  be  taken 


422 


POSTOPERATIVE    TREATMENT. 


off,  the  stitches  removed,  a  collodion  dressing  appKed,  and  the  limb 
put  up  in  a  plaster-of-paris  or  silicate  bandage.  In  small  children, 
and  in  any  case  in  which  there  is  much  curvature  of  the  femur,  it  is 
well  to  continue  the  bandage  up  around  the  pelvis,  otherwise  the  casing 
may  fail  to  get  a  sufficient  hold  upon  the  thigh.  After  about  six  weeks 
union  will  generally  be  firm  and  the  splint  may  be  left  off,  but  the  child 
should  be  kept  in  bed  for  two  or  three  weeks 
longer,  and  allowed  gradually  to  recover  the 
full  range  of  movement  in  the  knee. 

During  this  time  the  leg  should  be  massaged 
and  rubbed,  so  as  to  improve  the  circulation 
and  the  tone  of  the  muscles.  Walking  may 
be  permitted  in  about  ten  weeks,  and,  should 
the  rachitic  condition  of  the  bone  have  com- 
pletely passed  off,  no  further  apparatus  will  be 
required.  When  the  osteotomy  has  been  done 
upon  a  young  adult  in  whom  there  is  some 
doubt  as  to  whether  the  bones  have  become 
firmly  consolidated,  it  is  well  for  the  patient, 
after  operation,  to  wear  one  or  other  of  the 
forms  of  apparatus  which  are  usually  employed 
to  exert  mechanical  pressure  upon  the  de- 
formity. This  generally  consists  of  an  outside 
iron  fastened  to  the  pelvis  above  and  the  heel 
of  the  boot  below,  and  furnished  with  hinges 
opposite  the  hip-joint,  knee-joint,  and  ankle- 
joint  (see  Fig.  138).  There  is  also  generally 
a  band  or  sling  which  tends  to  draw  the  knee 
outward  against  the  iron.  This  apparatus  can 
be  made  of  quite  light  material,  and  should  be 
worn  for  two  or  three  months  after  operation. 
Should  genu  valgum  occur  after  excision  of  the  knee,  the  choice 
will  lie  between  a  fresh  excision  or  Macewen's  operation;  in  most  cases 
the  latter  is  less  severe  and  is  an  equally  satisfactory  method.  Should 
genu  valgum  occur  in  connection  with  infantile  paralysis,  the  usefulness 
of  the  limb  will  have  to  be  taken  into  consideration;  in  some  cases  it 
may  be  best  to  perform  excision  of  the  knee-joint,  so  as  to  give  the  pa- 
tient a  firm  and  fixed  point  of  support,  while  in  others  in  which  the  mus- 
cles are  fairly  healthy,  a  Macewen's  operation,  or  any  of  the  other  opera- 
tive procedures  which  we  have  mentioned,  may  be  employed.     (Cheyne.) 


Fig.  138. — Outside  Irons 
FOB.  Use  after  Opera- 
tion FOR  Genu  Val- 
gum IN  Adults. — 
{Erichsen.) 


CHAPTER  XIX. 

VALUE  OF  RONTGEN-RAY  IN  POSTOPERATIVE 
TREATMENT;  MANNER  OF  APPLICATION. 


CHAPTER    XIX. 

VALUE    OF    RONTGEN-RAY    IN    POSTOPERATIVE    TREAT- 
MENT;  MANNER  OF  APPLICATION. 

RONTGEN-RAY   THERAPY. 

General  Considerations. — Since  the  discovery  of  the  therapeutic 
value  of  the  Rontgen-rays  in  certain  forms  of  chronic  skin  diseases,  a 
large  number  of  medical  men  have  been  engaged  in  testing  the  effects  or 
determining  the  value  of  these  rays  by  actual  clinical  demonstrations 
upon  various  forms  of  malignant  growths,  the  result  being  that,  while  the 
curability  of  the  large,  deep-seated,  hard,  and  especially  internal  cancers, 
is  still  a  matter  of  impossibility  by  means  of  any  apparatus  yet  devised, 
there  can  be  no  doubt  that  superficial  cancers,  especially  the  epithe- 
liomas and  the  softer  varieties  of  mammary  cancer,  and  some  forms  of 
tuberculous  enlargements,  are  curable  by  this  means,  yet  the  fact  remains 
that  even  in  these  cases  the  cure  in  the  majority  of  instances  is  more 
quickly  and  more  satisfactorily  accomplished  by  operative  measures. 

The  experience  of  the  author,  which  has  been  somewhat  extensive, 
fully  agrees  with  the  statement  already  advanced  by  Leonard,  Lund, 
and  others,  and,  in  fact,  now  generally  conceded  by  unbiased  obser^'ers, 
that  the  Rontgen  rays  should  not  be  employed,  as  a  rule,  as  a  prehmi- 
nary  method  of  treatment  except  in  cases  distinctively  inoperable,  or 
when  cosmetic  effects  are  desired,  and  life  is  not  threatened  by  delay. 

It  has  also  been  the  author's  experience  that  even  in  cases  of  epithehal 
cancer,  the  application  of  escharotics,  in  case  the  patient  refuses  other 
operative  treatment,  as  a  preliminary  measure,  often  proves  highly  bene- 
ficial, and  increases  greatly  the  therapeutic  action  of  the  Rontgen-ray,  and 
shortens  greatly  the  time  required  for  treatment.  In  all  other  cases  of 
any  magnitude  surgical  treatment  should  always  precede  the  appHcation 
of  the  rays.  It  would  be  manifestly  absurd  to  attack  by  radiotherapy 
a  large  scirrhous  cancer  of  the  breast,  the  removal  of  which,  even  if 
possible  by  this  means,  would  require  many  months  of  treatment,  when 
an  equally  favorable,  if  not  better,  result  would  be  obtained  in  the  course 
of  a  few  days  by  extirpation.  Again,  the  liabihty  of  flooding  the  system 
with  toxins  by  causing  rapid  destruction  and  absorption  of  cancer  tissue 

425 


426  POSTOPERATIVE    TREATMENT, 

or  growths  of  low  vitality  has  not  by  any  means  been  exaggerated.  When 
insisting  upon  Rontgen-ray  treatment,  the  patient  should  be  informed 
upon  this  subject. 

Dosage  and  Method  of  Treatment. — Many  writers  affirm  that 
the  source  of  electric  energy  and  choice  of  apparatus  are  of  secondary 
importance,  provided  a  proper  tube  is  used,  the  static  machine  or  the 
coil  giving  equally  good  therapeutic  results.  In  the  author's  opinion, 
nothing  could  be  more  fallacious  or  misleading.  Famiharity  with  and 
constant  use  of  both  forms  of  apparatus  have  convinced  me  that  the 
larger  coils  are  far  more  valuable  in  Rontgen-ray  therapy,  and  only  by 
their  use  may  we  expect  in  the  future  greater  success  and  more  permanent 
effects  than  are  now  supposed  to  be  possible.  This  country  is  flooded 
with  cheap  static  machines  and  other  apparatus,  and  many  failures  are 
due  to  the  employment  of  inadequate  dosage.  In  the  treatment  of 
malignant  growths  I  have  long  since  abandoned  the  use  of  the  ponderous 
glass  static  machine.  Rontgen-ray  dosage  is  just  as  important  in 
Rontgen-ray  therapy  as  the  action  or  knowledge  of  drugs  in  physical 
ailment,  and  when  Rontgen-ray  administration  can  be  so  regulated  as 
to  produce  certain  effects  in  all  cases,  scientific  dosage  can  then  be  de- 
termined upon.     All  tubes  should  be  carefully  tested  as  to  penetration. 

The  degree  of  vacuum  in  a  Crookes  tube  is  more  accurately  deter- 
mined by  the  internal  resistance  of  the  tube  than  in  any  other  way.  You 
will  determine  this  by  connecting  to  the  terminals  of  the  exciting  appara- 
tus without  having  spark  gaps  in  series ;  then  by  bringing  the  discharge 
rods  or  other  conductors  connected  to  the  prime  conductors  within  a 
short  distance  of  each  other,  a  point  will  be  reached  where  the  current 
will  pass  between  the  discharge  rods  rather  than  through  the  tube.  If 
the  resistance  of  the  tube  be  low,  the  spark  gap  will  be  short,  whereas, 
if  the  resistance  of  the  tube  be  high,  the  spark  gap  will  be  longer  in  pro- 
portion to  the  degree  of  vacuum. 

In  making  this  test  as  to  the  degree  of  vacuum,  a  spark  gap  should 
not  be  used  in  series  with  the  tube,  because  a  spark  gap  sets  up  an  in- 
ductive action  which  produces  a  counter- electromotive  force  in  the  stems 
of  the  tubes  supporting  the  terminals,  and  would  cause  additional 
resistance  on  this  account.  For  example,  a  tube  that  will  back  up  a 
spark  gap  of  one-half  inch  without  spark  gaps  in  series  should  back  up 
only  an  inch  and  a  half  with  two  one-half  inch  spark  gaps  in  series  with 
the  tube,  but  it  will  be  found  that  with  the  spark  gap  in  series  the  tube 
will  back  up  a  much  longer  spark  gap  than  an  inch  and  a  half,  showing 


PLATE  V. 


Postoperative  Keloid  Growth   or  Tumor  Following  an  Operation  for 
Abscess  of  Right  Kidney. 

Growth  removed  by  the  combined  use  of  escharotics  and  X-ray. 


VALUE    OF   RONTGEN-RAY.  429 

that  the  counter-electromotive  force  developed  in  the  stems  or  metal 
terminals  of  the  tube  is  quite  great.  This  varies  according  to  the  con- 
struction of  the  tube.  The  use  of  auxiliary  anodes  greatly  overcomes 
this  factor,  so  that  tubes  of  different  types  vary  in  this  respect.  The 
tube  with  the  least  internal  resistance  for  a  given  degree  of  vacuum  is 
undoubtedly  the  best  for  both  Rontgen-ray  and  therapeutic  purposes. 
(Wagner.) 

In  applying  the  Rontgen-ray  treatment  the  technic  is  simple  but 
subject  to  great  modifications  according  to  the  experience  of  the  operator, 
nature  and  extent  of  the  grov^th,  idiosyncrasies  of  the  patient,  and 
variety  as  well  as  penetration  of  the  tube  used.  The  duration  of  ex- 
posure and  the  distance  of  the  tube  from  the  field  vary  considerably, 
and  a  knowledge  of  these  can  be  obtained  only  by  actual  experiment. 

The  distance  of  the  tube  from  the  parts  treated  must  vary  at  times 
from  3  to  10  inches,  and  the  time  of  exposure  varies  from  five  to  fifteen 
minutes.  It  is  the  author's  custom  to  commence  treatment  with  the 
tube  at  a  distance  of  lo  to  12  inches,  gradually  decreasing  the  distance 
as  the  patient  becomes  accustomed  to  its  effects,  or  the  parts  treated 
indicate  closer  or  stronger  application.  As  to  the  frequency  of  treat- 
ment, much  depends  upon  the  effect  produced  or  noticed.  Daily  treat- 
ment is  frequently  necessary  at  first;  later,  once  or  twice  a  week  will 
usually  prove  sufficient.  In  dealing  with  morbid  growths,  there  is  a 
strong  probability  that  the  rays  act  cumulatively;  therefore,  if  signs  of 
dermatitis  or  erythema  appear,  the  treatment  should  be  suspended  until 
they  have  subsided.  If  the  effects  of  the  Rontgen-ray  treatment  are 
pronounced,  the  length  of  time  of  exposure  during  treatment  should  be 
lessened,  or  the  tube  moved  farther  from  the  part  treated,  extreme  care 
being  necessary  to  prevent  overstimulation  of  the  absorbents.  Should 
this  condition  of  overstimulation  occur,  all  beneficial  action  may  sud- 
denly cease,  and  further  treatment  will  have  to  be  suspended  imtil,  by 
rest,  the  circulation  of  the  p(arts  improves  and  the  tissues  and  absor- 
bents return  to  their  normal  condition. 

Some  writers  contend  that  no  eft'ect  is  noticeable  upon  the  deep- 
seated  carcinomatous  disease  until  reaction  of  the  tissues  about  the 
growth  occurs.  They  therefore  aim  to  use  a  high- vacuum  tube  with  an 
amount  of  penetration  sufficient  to  produce  this  reaction  quickly.  There 
can  be  no  question  that  this  theory  is  correct.  The  absorbents  should 
be  stimulated,  but,  as  before  stated,  should  never  be  overs timulated, 
for  if  stimulated  beyond  their  capacit}',  negative  results  must  follow. 


43° 


POSTOPERATIVE    TREATMENT. 


Exposures  for  deep-seated,  malignant  growth  should,  therefore,  not  be 
given  oftener  than  two  or  three  times  a  week,  commencing  with  five-  to 
ten-minute  exposures,  and  increasing  the  length  of  time  according  to  the 
effects  produced  upon  the  affected  part. 

Effects  of  Treatment. — The  claims  made  for  Rontgen-ray  treat- 
ment in  surface  malignant  growths  of  all  types  are  summed  up  as  follows 
by  Morton:  (i)  Rehef  from  excruciating  pain  and  constant  suffering; 
(2)  reduction  in  size  of  growth;    (3)  establishment  of  process  of  repair; 

(4)  removal  of  odor  if  present;  (5)  the 
cessation  of  the  discharge;  (6)  softening 
and  disappearance  of  lymphatic  nodes; 
(7)  disappearance  of  lymphatic  nodes 
not  directly  submitted  to  treatment,  and 
often  quite  distant;  (8)  removal  of 
cachectic  color  and  appearance  of  the 
skin;  (9)  improvement  in  general  health; 
(10)  cure  of  many  undoubtedly  malig- 
nant growths,  confirmed  by  absence  of 
relapse  after  many  months  of  observation. 
The  results  obtained  from  the  rays 
for  postoperative  recurrence  or  in  inop- 
erable cases  are  shown  in  a  paper  written 
by  Holding.*  He  reports  148  cases  col- 
lected from  literature,  with  four  of  his  own 
in  addition.  A  study  of  these  cases 
shows  that  32  percent  were  apparently 
cured,  58  percent  were  improved,  and 
only  10  percent  unimproved.  As  noted 
before,  the  most  favorable  results  were  obtained  in  cases  of  superficial 
growth,  such  as  epithelioma  of  the  face  and  mammary  carcinoma. 

Of  the  six  cases  reported  by  Pusey  of  intra-abdominal  cancer,  the 
result  was  unfavorable  in  every  instance.  Turner  reports  (London 
"Lancet")  18  cases  of  inoperable  recurrent  malignant  disease.  Marked 
improvement  was  shown  in  all,  but  the  best  results  were  obtained  in  the 
mammary  cases.  He  also  noted  diminution  of  pain,  loosening  of 
adhesions,  and  relief  from  contracting  and  tightening  sensation. 

Bryant  reports  cases  of  recurrent  or  inoperable  cancer  of  the  rec- 
tum which  were  amenable  to  Rontgen-ray  treatment. 

*  "Albany  Medical  Annals,"  Feb.,  1903. 


Fig.   139. — Rontgen-ray    Tube 
WITH  Vacuum  Control. 


VALUE   or   RONTGEN-RAY. 


431 


Roswcll  Park,*  in  an  article  u]X)n  the  subject,  concludes  as  follows: 
The  Rontgen-rays  afford  a  method  of  treatment  for  extremely  new 
growths  of  limited  area  and  superficial  character  which,  while  not  exactly 
certain,  is  extremely  promising.  They  not  only  cause  no  pain,  but  tend 
to  relieve  pain,  both  superficial  and  deep,  in  a  most  satisfactory  manner. 
They  are  adapted  to  cases  which  can  hardly  be  submitted  to  any  other 
method  of  treatment,  and  they  afford  more  hope  in  recurrent,  delayed, 


Fig.  140. — GuNDELACH  Tube  with  Heavy  Anode. 

or  inoperable  cases  than  any  other  method  of  treatment.  More  than 
this,  the  rays  afford  a  supplementary  method  of  t-reatment  after  opera- 
tion, by  which  the  benefits  of  the  same  may  be  enhanced  and  enlarged. 

Character  and  Kind  of  Tube. — The  majority  of  observers  agree 
that  for  the  treatment  of  superficial  growths,  soft  tubes  or  tubes  of  low 
resistance  are  preferred;    and  for  deeper  growths,  hard  tubes  or  those 


Fig.  141. — Hard-rubber  Mask. 

of  high  resistance  are  necessary.  The  ordinary  tubes  have  such  change- 
able vacuums  that  they  are  unsuited  for  Rontgen-ray  therapy,  and  only 
those  tubes  which  permit  perfect  control  of  the  vacuum  should  be  em- 
ployed (Fig.  139). 

The  author  prefers  high-vacuum  tubes  because  they  give  good  re- 
sults in  the  treatment  of  the  deeper  tissue,  not  affected  by  low-vacuum 

*  "Med.  News,"  May  30,  1903. 


432 


POSTOPERATIVE    TREATMENT. 


VALUE    OK   RONTGEN-RAY.  433 

tubes,  while  the  high-vacuum  tuljcs  give  equally  as  gorKl,  if  n(;t  better, 


Fig.   143. — Showing  Manner  of  Applying  the  Rontgen  Rays  to  Tuberculous 

Knee. 

results  in  the  treatment  of  superficial  conditions,  provided  a  little  longer 
exposure  is  made. 

The  author  prefers  for  su-      /^ 


perficial  work  the  ordinary  ^ 
"Gold-Medal"  or  Wagner's 
adjustable  focus  tube  (Fig. 
142);  for  deep  penetration, 
the  improved  large-sized  R. 
F.   universal    regulating:   tube 


Fig.  144. — Caldwell  Tube. 


(or  Gundelach  heavy  anode  tubes)   (Fig.  140). 


29 


434 


POSTOPERATIVE    TREATMENT. 


For  rectal  or  vaginal  treatment,  the  Caldwell  tube  is  preferable 
(see  Fig.  144).     These  tubes  are  made  with  a  water-jacket  and  the 


Fig.  145- 


Fig.  146. 


Fig.  147.  Fig.  148. 

Types  of  Epithelioma  Cured  by  Rontgen-ray  Treatment. 

cathode   so   arranged   that  the   main   direction   of   the   Rontgen-rays 
emitted   is    at    an   angle  to  the   axis    of   the   tube,  the    anode  being 


VALUE   OF   RONTGEN-RAY.  435 

grounded.  It  is  introduced  within  the  vagina,  and  a  Pennington  brass 
shield  is  used  if  it  is  desired  to  limit  the  area  of  radiance. 
Owing  to  the  fact  that  the  tube  is  brought  in  close  contact  with 
the  parts  under  treatment,  the  duration  of  exposure  must  be  lessened 
in  accordance  therewith. 

Manner  of  Protecting  the  Patient. — In  place  of  the  cumbersome 
lead  screens  heretofore  eniployed,  the  author  uses  a  hard-rubber  mask 
(see  Fig.  141). 

The  Friedlander  protective  shield,  although  somewhat  heavier,  is 
equally  efficacious.  It  not  only  protects  the  patient,  but  also  the  eyes 
of  the  operator,  and  admits  of  easy  adjustment  of  the  rays. 


CHAPTER  XX. 
COMPENSATIVE  OR  ARTIFICIAL  APPLIANCES. 


CHAPTER  XX. 
COMPENSATIVE  OR  ARTIFICIAL  APPLIANCES. 

Where  and  How  to  Amputate. — L.  E.  Jepson  slates  that  for  many 
years  efforts  have  been  made  to  construct  a  substitute  for  the  natural 
limb,  or  to  restore,  in  a  measure  at  least,  the  functional  uses  of  the  am- 
putated member.  While  great  advance  has  undoubtedly  been  made 
and  the  work  of  the  ingenious  inventor  greatly  appreciated  by  patients, 
nevertheless  the  results  will  be  far  more  satisfactory  and  gratifying  when 
the  operating  surgeon  realizes  the  necessity  of  working  more  in  harmony 
with  the  prosthetist.  This  matter  has  already  been  referred  to  briefly 
on  page  378,  but  as  there  seems  to  be  so  very  little  reference  to  this  sub- 
ject in  our  modern  text-books,  we  deem  it  advisable  to  present  the  views 
of  an  authority  upon  this  interesting  subject. 

The  anatomic  facts  regarding  conditions  of  amputations  requir- 
ing investigation  may  be  sumtnarized  by  the  enumeration  of  certain 
difficulties  experienced  in  a  large  majority  of  the  amputations  of  the 
leg  at  any  point  below  the  junction  of  the  middle  and  lower  third,  or 
the  "point  of  election"  (nine  to  ten  inches  below  the  knee). 

The  following  are  such  difficulties: 

(A)  In  a  LiSFRANC,  tarsometatarsal  or — 

(B)  A  Chop  ART,  mediotarsal  amputation,  the  equilibrium  of 
the  tarsals  forming  the  arch  is  destroyed,  becoming  simply  a  heap  of 
angular  fragments  and  almost  invariably  producing  pressures  and  irri- 
tations, causing  severe  pain  from  its  use.  In  a  tarsometatarsal  or  a 
mediotarsal  amputation  the  tendo  Achillis  almost  always  contracts  to 
such  an  extent  as  to  pull  the  heel  up  and  the  amputated  surface  down, 
thereby  elongating  the  stump  and  making  necessary  an  artificial  leg 
which  will  not  touch  the  end,  and  the  use  of  an  elevated  sole  on  the  other 
foot  to  counteract  the  extra  length.  In  a  mediotarsal  amputation  the 
astragalus  is  very  liable  to  become  displaced  from  its  intermalleolar 
position  causing  serious  trouble. 

(C)  A  tibiotarsal  amputation  (Pirogoff  or  Syme)  at  the 
ankle-joint,  even  with  the  most  favorable  results,  which  are  seldom 
secured,  necessitates  a  large  and  cumbersome  appliance  about  the  ankle, 

439 


440 


POSTOPERATIVE    TREATMENT. 


and,. moreover,  seldom  gives  comfort  or  satisfaction  to  the  wearer.  With 
the  foregoing  amputations  it  is  many  times  mechanically  impossible  to 
secure  a  satisfactory  fit  and  adjustment  for  prosthetic  apparatus. 

(D)  In  AMPUTATIONS  OF  THE  LEG  between  the  "point  of  election" 
and  the  ankle  it  was  observed  and  noted  that  the  healing  process  was 
long  and  stubborn,  while  a  certain  percentage  of  such  cases  absolutely 
refused  to  heal  in  a  satisfactory  manner.  It  was  further  noted  that 
almost  invariably  the  stump  was  extremely  sensitive  to  heat,  cold,  and 
the  touch,  and  also  subject  to  sweUing,  ulceration,  and  abscess.  It 
was  again  noted  that  the  patient  usually  elevated  the  stump  to  the  highest 


A.  A.  MARKS.  N 


Fig.  149. — Chopart  Amputation. 


Fig.  150. — Syme's  Amputation 
AT  Ankle-joint. 


position  in  sitting  or  reclining,  the  same  procedure  being  followed  by 
those  wearing  artificial  legs,  thereby  reducing  the  swelling  and  reheving 
the  throbbing,  bursting,  and  painful  feeHng  of  the  extremity.  It  was 
inferred  that  these  difficulties  were  the  result  of  deficient  circulation, 
and  an  anatomic  investigation  confirmed  the  theory  and  established 
the  fact.  At  about  the  middle  of  the  mid-third  and  in  the  foot  the  col- 
lateral circulation  is  found  to  be  complete,  but  between  these  two  points 
there  is  very  little  collateral  circulation.  It  therefore  follows  that  the 
extremity  of  a  stump  made  by  amputating  between  these  two  points 
is  practically  devoid  of  circulation,  the  blood  simply  stagnating  in  the 


.  COMPENSATIVE   OR  ARTIFICIAL  APPLIANCES.  44I 

end,  resulting  in  a  swollen,  inflammatory  condition  which  nature  tries 
to  relieve  by  ulceration  and  abscess.  The  most  satisfactory  place  of 
amputation  below  the  knee  is  the  middle  of  the  mid-third,  and  at  this 
point  the  best  results  are  secured  from  a  prosthetic  point  of  view. 

(E)  Amputation  of  the  leg  higher  than  the  junction  of  the  upper 
and  the  middle  thirds  detracts  from  the  use  of  the  stump  in  throwing  the 
leg  forward  in  walking.  In  these  amputations,  especially  those  made 
just  below  or  near  the  head  of  the  fibula,  it  was  observed  that  the  lower 
end  of  the  fibula  was  a  constant  source  of  trouble  in  wearing  an  artificial 
leg.  The  stump  becomes  more  and  more  atrophied  by  wearing  an 
artificial  leg,  and  the  more  the  shrinkage,  the  more  prominent  the  fibula. 
The  trouble  is  caused  by  this  lower  end  of  the  fibula  rotating  outward 
and  coming  in  contact  with  the  socket  of  the  artificial  leg,  often  resulting 
in  periostitis  and  almost  invariably  in  an  enlarged,  sore,  and  irritable 
condition  and  extremely  sensitive  to  the  touch.  Many  times  it  has 
been  absolutely  necessary  to  have  it  removed  before  an  artificial  leg 
could  be  worn  with  any  degree  of  comfort.  In  the  present  advanced 
state  of  surgery  it  is  no  more  of  a  major  operation,  while  the  amputa- 
tion is  being  made,  to  remove  the  fibula.  The  objections  against  re- 
moving the  fibula  entire  are  more  theoretical  than  practical,  being 
mainly  that  the  leverage  might  be  somewhat  lessened  by  taking  out 
the  head  of  the  fibula,  also  the  very  slight  risk  of  opening  the  knee-joint. 

A  single  longitudinal  incision  on  the  outer  side  of  the  fibula 
exposes  the  bone.  The  periosteum  being  carefully  separated  and  the 
bone  separated  from  its  ligamentous  attachment  can  be  removed  with- 
out destroying  the  action  of  the  external  hamstring  or  biceps  tendon. 
While  this  tendon  is  inserted  into  the  head  of  fibula  it  also  embraces 
the  external  lateral  ligament  of  the  knee-joint,  and  has  a  strong  attach- 
ment to  the  outer  tuberosity  of  the  tibia.  The  short  fibula  has  no  func- 
tion whatever,  and  at  the  best  makes  an  ill-shaped  stump  and  its  re- 
moval obviates  all  difficulties.  Although  this  may  be  considered  an 
innovation,  yet  experience  warrants  the  statement  that  in  these  short 
amputations  it  should  always  be  removed. 

(F)  Amputations  at  the  knee  as  formerly  made  often  resulted 
in  tender,  irritable,  and  sensitive  stumps ;  but  with  a  proper  amputation, 
they  are  most  useful  and  satisfactory.  In  such  cases  the  end  of  the 
femur  must  not  be  disturbed,  the  condyles  untrimmed,  and  the  cicatrices 
carried  high  from  the  end  with  posterior  flaps.  If  the  patella  is  un- 
injured, an  experienced  and  skilful  surgeon  may,  under  favorable  cir- 


442  POSTOPERATIVE    TREATMENT. 

cumstances,  successfully  bring  it  down  over  the  end  of  the  femur  and 
place  it  in  the  depression  between  the  condyles,  nevertheless ;  from  our 
experience,  we  believe  it  is  better  to  remove  it,  for  whenever  the  patella 
withdraws  from  the  intercondylar  notch  it  presents  serious  difficulties 
in  wearing  an  artificial  leg. 

(G)  Amputations  of  the  thigh  made  too  close  to  the  knee  do 
not  leave  room  for  the  artificial  knee.  The  amputation  should  be  made 
three  or  four  inches  above  the  knee.  Whenever  it  is  necessary  to  am- 
putate higher  than  the  junction  of  the  middle  with  the  lower  third, 
every  inch  possible,  and  consistent  with  a  good  flap,  should  be  saved. 

(H)  The  position  oe  the  cicatrix  it  was  also  found  by  prac- 
tical observation  in  fitting  limbs,  had  much  to  do  with  the  comfort  of 
the  patient  in  wearing  limbs.  The  cicatrix  should  never  come  over 
the  end  or  anterior  part  of  the  stump.  If  a  long  anterior  flap  is  used 
the  cicatrix  can  fall  posteriorly.  The  position  of  the  scar  has  been 
largely  changed  to  accommodate  the  artificial  limb. 

(I)  The  bone  should  be  sacrificed  to  the  perfection  of  the  flap 
if  the  amputation  is  to  be  made  below  the  middle  of  the  mid-third.  If 
the  amputation  is  to  be  made  above  the  middle  of  the  mid-third  the  per- 
fection of  the  flap  should  be  sacrificed  to  the  length  of  the  bone.  To 
secure  leverage,  every  inch  above  the  middle  of  the  mid-third  should 
be  saved. 

(J)  Postoperative  Condition  of  Nerves. — One  of  the  most 
serious  defects  in  amputating  was  found  to  result  from  leaving  the  nerves 
exposed  too  near  the  extremity,  resulting  in  an  irritable  and  painful 
condition,  and  often  resulting  in  neuroma.  It  has  been  necessary  to 
advise  many  patients  to  undergo  an  operation  to  correct  the  results  of 
ignorance  of  this  fact  in  amputation. 

(K)  Postoperative  Conditions  of  Bone. — It  was  also  observed 
that  serious  results  followed  the  leaving  of  sharp  edges  and  corners  of 
bone,  which,  upon  attempting  to  apply  an  artificial  leg,  caused  tender, 
irritable,  and  sore  places,  the  bone  at  times  actually  piercing  the  skin. 
All  edges  and  sharp  corners  should  be  well  rounded  off. 

(L)  Redundant  tissue  on  the  end  of  the  stump  is  a  positive  detri- 
ment, and  produces  evil  results  by  easily  becoming  inflamed  and  tender. 
The  extremities  should  be  well  covered,  but  nothing  more. 

(M)  The  Size  of  the  Stump. — It  was  found  that  in  most  cases,  as 
the  result  of  improper  treatment,  the  stump  had  been  allowed  to  become 
abnormally  large.     There  is  a  tendency  with  most  stumps  soon  after 


COMPENSATIVE   OR   ARTIFICIAL   APPLIANCKS. 


443 


healing  to  take  on  adipose  tissue,  tliereby  becoming  large,  soft,  and 
flabby.  Many  surgeons  seem  to  believe  that  an  attenuated  stump  was 
a  misfortune.  This  has  been  one  of  the  greatest  errors  and  most  preva- 
lent evils  that  have  had  to  be  met  and  overcome.  It  is  an  established 
fact  that  any  stump  when  left  to  itself  will  become  hypertrophied,  and  by 
wearing  an  artificial  leg  will  become  atrophied.     It  is  therefore  wise  to 


Fig.  151. — Shows  Construction  of 
Artificial  Limb;  for  Amputation 
Six  Inches  below  the  Knee. 


Fig.  152. — One  of  the  Late  Devices, 
Double  Socket  Artificial  Limb; 
for  Amputation  below  the  Knee. 
Improved  Felt  Foot. 


minimize  the  shrinkage  of  the  stump  as  the  result  of  wearing  an  artiJicial 
leg,  and  thereby  minimize  the  necessary  changes  in  the  socket  to  counter- 
act such  shrinkage.  It  was  further  found  that  in  most  cases  of  attempted 
treatment  the  stump  was  imperfectly  prepared  at  the  best.  The  old 
method  was  to  bandage  tightly,  retarding  the  circulation,  producing 
uneven  shrinkage  and  affording  no  protection  from  accident.     Again, 


444 


POSTOPERATIVE    TREATMENT. 


whenever  a  stubborn  hypertrophied  stump  failed  to  yield  to  bandages 
it  was  thought  necessary  to  apply  a  temporary  artificial  leg  in  order  to 
reduce  the  stump,  which  was  done  at  the  inconvenience  and  expense  of 
the  wearer. ,  This  method  was  everywhere  prevalent  and  among  all 
manufacturers.  In  the  place  of  the  bandage  and  temporary  artificial  leg 
there  has  now  been  substituted  a  leather  corset,  lacing  about  the  stump 
and  producing  by  its  firm  and  evenly  distributed  pressure  rapid  and 
uniform  shrinkage,  giving  a  conical  shape,  which  is  greatly  to  be  desired, 
and  all  this  has  been  done  without  interfering  with  the  circulation. 
This  treatment  also  affords  a  most  perfect  protection  against  injury 
from  accident. 

General  Remarks. — The  artificial  leg  must  be  as  light  as  possible, 
but  should  be  of  sufficient  weight  to  assure  the  wearer  sufficient  strength 


A.  MARKS.  N.  V. 


Fig. 


153. — Improved  Sponge  Rubber 
tooT,  WITH  Ankle-joint. 


Fig. 


154. — Showing    Mexican    Felt 
Foot  with  Ankle-joint. 


not  only  to  carry  the  weight  of  the  body,  but  to  withstand  the  require- 
ments of  his  occupation.  By  the  use  of  the  best-grade  material,  skill, 
and  painstaking  workmanship,  the  limb  may  be  made  exceptionally 
light  in  weight  and  also  strong  and  durable  (see  Figs.  151,  152). 

Some  prefer  the  rubber  foot.  It  cannot  be  made  as  light,  however, 
as  a  willow,  wood,  or  felt  boot. 

The  location  of  the  weight  in  an  artificial  leg  has  much  to 
do  with  its  seeming  heaviness ;  thus,  two  legs  made  for  the  same  person, 
each  weighing  five  pounds,  one  may  feel  very  heavy  and  the  other  light. 
A  leg  with  a  light  upper  part  and  a  heavy  foot  would  be  called  a  heavy 
leg,  and  a  leg  with  a  heavy  upper  part  and  a  light  foot  would  be  pro- 
nounced a  light  leg. 

The  majority  of  artificial  legs  are  worn  by  the  laboring  classes,  their 


COMPENSATIVE   OR  ARTIFICIAL   APPLIANCES.  445 

occupation  subjecting  them  to  more  frequent  injury.  Comparatively 
few  are  financially  able  to  purchase  a  duplicate  artificial  leg,  hence  the 
leg  should  be  made  as  strong  and  durable  as  possible,  that  repairs  and 
loss  of  time  may  be  avoided,  and  due  consideration  should  be  given  in 
selecting  and  purchasing  an  artificial  limb. 

Children  requiring  artificial  limbs  should  be  fitted  so  soon  as  possible ; 
as  early  as  the  fourth  or  fifth  year  they  may  be  adjusted  and  worn  with 
comfort.  Adjustable  limbs  adapted  for  the  growing  child  have  now 
been  perfected  and  are  quite  satisfactory.  The  most  graceful  and  easy 
walkers  are  those  who  commence  the  use  of  the  artificial  leg  in  youth, 
and  by  the  time  they  are  grown  it  has  become  second  nature  to  wear  a 
leg. 

How  to  Prepare  a  Stump  for  an  Artificial  Limb. — It  is  of  great 
importance  that  the  stump  be  prepared  before  being  fitted  into  an  artifi- 
cial leg.  This  is  accomplished  ordinarily  by  keeping  the  stump  tightly 
bandaged  from  the  time  it  is  sufficiently  healed  until  the  artificial  leg  is 
worn.  Bandage  from  the  end  of  the  stump  to  the  knee  if  the  amputation 
is  below,  or  to  the  body  if  the  amputation  is  above,  the  knee. 

The  tight  bandage  seems  to  solidify  and  tighten  the  stump,  which 
otherwise  becomes  soft  and  flabby.  Some  of  the  manufacturers  prefer 
the  leather  corset,  claiming  that  it  is  better,  holds  the  limb  in  position 
more  firmly,  is  more  easily  applied,  and  is  far  more  comfortable  to  the 
wearer,  and  also  tends  to  give  the  stump  the  desired  conical  shape. 

The  corset  should  be  worn  either  next  to  the  stump  over  a  well-fitted 
stump  stocking  or  a  thickness  of  the  underclothing,  according  to  the 
preference  of  the  wearer.  It  should  be  worn  continuously  day  and 
night,  and  adjusted  as  tightly  as  possible  without  causing  undue 
discomfort. 

If  the  amputation  has  been  made  below  the  knee,  the  knee-joint 
should  be  exercised  and  straightened  as  much  as  possible  to  prevent 
flexion  or  ankylosis.  Applications  of  electricity  and  massage  may 
frequently  be  used  to  advantage. 

Artificial  Hands  and  Arms. — Despite  the  unwarranted  and 
exaggerated  statements  of  certain  manufacturers,  no  artificial  hand  or 
arm  has  yet  been  devised  that  equals  in  benefit  artificial  legs,  nor  is  this 
possible  in  case  both  arms  have  been  amputated  above  the  elbow,  owing 
to  the  many  complicated  uses  of  an  artificial  hand. 

In  double  amputations  of  the  arms  the  greatest  benefit  in  wearing 
artificial  arms  is  the  improvement  in  appearances,  although  the  wearer 


446 


POSTOPERATIVE    TREATMENT. 


may,  in  the  course  of  time,  accomplish  considerable  along  the  lines  of 
helpfulness. 

A  valise  or  heavy  object  can  be  carried,  the  weight  coming  on  the 
shoulder-pad.  In  case  but  one  arm  has  been  amputated,  however, 
the  natural  hand  may  be  of  great  assistance,  enabling  the  artificial  arm 
to  assume  various  flexed  positions,  and,  owing  to  the  arrangements  of 

the-  shoulder-straps,  the  artificial  hand  may 
Kkewise  be  of  great  assistance  to  the  natural. 
Many  laboring  men  prefer  a  simple  hook,  and 
great  utihty  may  be  derived  in  wearing  such  a 
contrivance.  The  rubber  hand  is  preferred  by 
many,  for  the  reason  that  it  possesses  a  flesh- 
like softness.  The  fingers  and  thumb  may  be 
bent  or  placed  in  the  desired  position  with  the 
natural  hand,  and  they  will  remain  in  this  posi- 
tion until  rearranged.  The  artificial  hand 
may  be  thus  arranged  and  controlled  by  a 
button  or  spring  enabling  them  to  hold  a  knife, 
fork,  brush,  etc. 

Fig.  155  illustrates  one  of  the  latest  and 
most  complete  devices  or  substitutes  for  an 
artificial  hand.  By  pressing  a  button  at  (a) 
the  hand  can  be  taken  off,  and  the  knife, 
fork,  brush,  or  hook  or  any  other  instrument 
can  be  inserted  in  the  end  of  the  wrist  as  well 
as  the  palm  of  the  hand.  The  spring  con- 
trolled by  the  button  (a)  retains  the  tools  in 
the  end  of  the  wrist,  while  the  spring  controlled  by  the  button  (d)  re- 
tains tools  in  the  palm  of  the  hand.  The  hand  and  wrist  attachments 
are  the  same  for  all  amputations.  When  manual  work  is  required, 
the  hand  is  removed  and  the  hook  inserted  in  the  forearm  (see 
Fig-  155)- 


Fig.  155. — Substitute  for 
Artificial  Hand. 


CHAPTER  XXI. 
POSTOPERATIVE  DIETETICS. 


CHAPTER   XXI. 
POSTOPERATIVE  DIETETICS. 

The  feeding  of  patients  after  operation  is  one  of  the  very  important 
elements  in  after-treatment.  The  effect  of  food  itself,  as  food,  is  prob- 
ably a  minor  factor  as  compared  with  the  complications  it  may  produce, 
largely  in  a  mechanical  way,  when  injudiciously  administered.  Chief 
among  these  are  nausea  and  its  frequent  successor,  vomiting,  either 
of  which  may  result  later  in  serious  deprivation  of  food  which  the  pa- 
tient urgently  requires.  The  latter  not  only  more  effectually  than  nausea 
prevents  the  taking  of  food,  but  also  adds  the  element  of  physical  strain, 
with  the  possible  opening  of  wounds,  contamination  of  operative  sites, 
and  the  general  hindrance  of  reparative  and  recuperative  processes 
throughout  the  body. 

Postoperative  feeding  depends  to  some  extent  upon  the  plan  adopted 
in  preparing  the  patient  for  the  operation,  but  is  so  largely  a  matter  by 
itself  that  the  former  may  for  practical  purposes  be  disregarded.  Suf- 
fice it  to  say  that  modern  methods  of  preparation,  which  have  shown 
the  fallacy  of  the  older  belief  in  pronounced  starvation  as  a  prehminar)-, 
now  leave  the  patient  in  a  much  better  physical  and  mental  condition 
to  undergo  the  deprivation  of  food  absolutely  necessary  after  surgical 
intervention.  By  judicious  feeding  before  operation,  in  all  but  emer- 
gency cases  much  can  be  done  to  prevent  postoperative  shock  and  aUied 
conditions,  the  presence  of  which  markedly  interferes  with  the  resump- 
tion of  nourishment.  This  question  has  been  discussed  in  the  chapter  on 
preparation,  and  the  statements  made  need  not  here  be  repeated. 

General  Rules  for  Postoperative  Feeding. — As  a  rule,  regard- 
less of  nausea  or  vomiting,  no  food  should  be  given  a  patient  by  the 
mouth  during  the  first  eighteen  hours  after  operation,  though  circum- 
stances may  render  advisable  departure  in  either  direction  from  this 
time  limit.  In  the  presence  of  positive  indications,  a  previously  well- 
nourished  adult  may  safely  go  without  food  for  two  or  even  three  days ; 
on  the  contrary,  either  very  young  or  old  and  exhausted  persons  must 
not  for  a  long  time  be  deprived  of  nourishment.  Fortunately,  both 
the  last-named  groups  are  relatively  free  from  the  disagreeable  effects 
30  449 


450  POSTOPERATIVE    TREATMENT. 

of  anesthesia,  and  often  retain  food  that  is  given  as  early  as  eight  to 
twelve  hours  after  operation.  A  number  of  surgeons  guard  against 
postoperative  nausea,  and  thus  favor  the  early  retention  of  food,  by 
v^ashing  the  stomach  with  warm  water,  until  the  latter  returns  clear, 
by  means  of  a  stomach-tube  introduced  while  the  patient  is  still  upon 
the  operating  table.  I  have  previously  mentioned  this  expedient  as  a 
preventive  of  shock  and  postoperative  thirst  in  all  major  operations; 
surgeons  who  do  not  adopt  this  as  a  routine  procedure  may  well  employ 
it  with  patients  whose  stomachs  have  been  specially  rebellious  before 
operation.  Persons  profoundly  exhausted  before  operation  may  soon 
after  require  nutrient  enemas  at  regular  intervals;  in  some  of  these 
cases  a  stimulant  and  nutritive  combination  of  beef-tea,  white  of  egg, 
and  brandy  may  be  placed  high  in  the  intestine  before  the  patient  leaves 
the  operating  room.  Patients  in  whom  operation  has  not  involved 
the  abdomen  usually  will  tolerate  feeding  earlier  than  those  in  whom 
the  peritoneum  has  been  disturbed. 

If,  then,  in  ordinary  cases  at  the  end  of  eighteen  hours  the  stomach 
has  for  some  time  been  perfectly  quiet,  the  fluid  which  has  been  given  to 
allay  thirst  may  be  made  to  include,  or  be  entirely  changed  to,  liquid 
nourishment.  This  must  be  given  in  spoonful  doses  only,  every  one  or 
two  hours,  until  the  retaining  power  of  the  stomach  is  tested.  The 
proper  beginning  of  food  depends  so  largely  upon  the  condition  of  the 
,  individual  patient  that  any  time  limit  is  in  a  sense  arbitrary ;  as  an  aid  in 
this  matter  a  careful,  observing,  and  experienced  nurse  is  at  this  period 
invaluable.  One  of  the  principal  objections  advanced  by  Hans  Kehr 
against  operating  in  private  houses  is  the  meddlesome  interference  of 
the  family  with  the  after-feeding  of  the  patient.  In  the  absence  of  a 
trained  nurse  in  particular,  but  in  every  case  in  general,  the  surgeon 
must  keep  himself  informed  regarding  every  detail  of  the  patient's 
behavior  and  must  give  definite  orders  when  to  begin  feeding  and  what 
the  food  is  to  be.  Should  vomiting  be  provoked  by  the  first  trial,  all 
fluids  must  be  withheld  for  two  or  three  hours ;  Vichy  water  may  then  be 
given.  Under  these  circumstances  McKay  is  partial  to  Semmola's 
glycerin  drink,  made  by  adding  i  ounce  of  glycerin  and  30  grains  of 
citric  acid  to  i  pint  of  water;  this  is  useful  from  the  beginning  in  allaying 
thirst.  Albumin-water,  made  by  straining  the  beaten  whites  of  eggs, 
or  better  draining  off  the  fluid  part  after  it  has  stood  for  an  hour,  diluting 
three  or  four  times  with  water,  and  adding  sugar  and  lemon-juice,  is  an 
ideal  substance  with  which  to  begin  the  feeding  of  patients.     It  is  better 


POSTOPERATIVE   DIETETICS.  45 1 

not  to  inform  them  what  they  arc  getting,  as  the  thought  of  raw  egg  may 
render  the  mixture  distasteful.  The  albumin-water  shoukl  be  freshly 
made  every  six  hours,  though  in  cold  weather  it  may  be  kept  at  least  twice 
this  length  of  time.  At  the  end  of  thirty  or  thirty-six  hours  the  albumin- 
water  may  be  substituted  by  peptonized  milk,  not  carried  to  the  point  of 
bitterness,  milk  and  Vichy,  milk  and  lime-water,  or  a  clear  broth.  One 
part  milk,  2  parts  cream,  and  2  parts  lime-water  is  a  mixture  that  agrees 
with  some  persons.  Given  at  first  in  spoonful  doses,  either  may,  if  well 
borne,  soon  be  increased  to  i  or  2  ounces  every  two  hours.  Idiosyncrasy 
of  the  patient  has  much  to  do  in  determining  the  selection  of  the  earlier 
diet-list.  Perhaps  of  no  substance  is  this  more  true  than  of  milk,  and 
before  giving  it,  inquiry  should  be  made  as  to  whether  it  agreed  with  the 
patient  during  health.  On  the  third  day  soft  foods  may  be  begun,  and 
two  days  later  be  followed  by  light  solids ;  at  the  end  of  a  week  ordinary 
diet  may  be  resumed. 

Diet  for  Laparotomy  Patients. — ^After  employing  liquid  nourish- 
ment in  increasing  amounts  and  at  lengthened  intervals  for  two  or  three 
days  the  patient  may  be  given  light  soft  foods  selected  from  a  list  includ- 
ing oyster  soup,  junket,  chicken  jelly,  various  forms  of  gruel,  etc.  Two 
days  later  there  may  be  added  chicken  or  mutton  broth  with  rice  or 
barley,  poached  or  very  soft-boiled  eggs,  dry  or  milk-toast,  oysters,  and 
other  soft  foods.  With  patients  who  present  no  disturbing  stomach 
conditions  after  operation  it  is  wise  early  to  discard  liquid  diet,  as  it  has 
a  tendency,  especially  in  such  persons,  to  cause  an  annoying  degree  of 
flatus.  After  four  or  five  days  McKay*  finds  gelatin  blanc-mange  a 
most  acceptable  food,  and  makes  a  routine  practice  of  giving  it  to  his 
section  cases.  He  prefers  the  following  formula:  Of  i  quart  of  fresh 
milk,  place  ij  pints  in  a  double-lined  saucepan.  Soak  i  "quart" 
packet  of  gelatin  in  the  remaining  |  pint  of  milk  for  two  hours.  Then 
stir  this  milk  and  gelatin  into  the  milk  in  the  saucepan,  now  brought  to 
the  boiling-point,  and  add  2  dessertspoonfuls  of  sugar  and  a  little  flavor- 
ing. After  three  minutes  remove  the  saucepan  from  the  fire  and  add  to 
the  contents  the  white  of  one  egg  which  has  been  beaten  to  a  froth. 
Now  turn  the  whole  into  a  shape  previously  cooled  in  cold  water,  allow 
the  contents  to  set,  and  place  the  shape  either  in  a  cool  place  or  in  an 
ice-chest.  By  the  end  of  a  week  the  diet  may  include  fish,  eggs,  oysters, 
squab,  chicken,  sweetbreads,  custards,  puddings,  and  the  like.  In 
uncomplicated  cases  ordinary  diet  may  be  resumed  by  the  tenth  or 

*"The  Preparation  and  After-treatment  of  Section  Cases,"  London,  1905. 


452  POSTOPERATIVE    TREATMENT. 

twelfth  day.  Vegetables  should  be  given  sparingly,  or  better  not  at  all, 
before  this  time.  This  statement,  unless  in  exceptional  cases,  applies 
also  to  fruits,  although  the  juice  of  oranges  and  lemons  may  be  taken 
much  earlier.. 

Diet  After  Operations  Upon  the  Stomach. — Competent  surgeons 
vary  greatly  regarding  the  time  at  which  to  begin  feeding  after  opera- 
tion upon  the  stomach.  Some  allow  milk  by  the  mouth  on  the  follow- 
ing day,  others  wait  four  to  eight  days,  nourishment  in  the  meanwhile 
being  supplied  by  rectal  feeding.  As  a  routine  it  is  better  to  supply 
food  in  the  shape  of  enemas,  if  they  be  tolerated,  for  at  least  two  days 
after  stomach  operations  of  any  magnitude.  Feeding  by  the  mouth 
may  then  be  begun  as  previously  indicated  for  section  cases  in  general. 
More  care  and  a  longer  time  are  required,  however,  in  increasing  the 
quantity  and  in  passing  to  the  more  substantial  materials.  The 
heavier  solids  should  not  be  allowed  until  the  beginning  of  the  fourth 
week.  When  a  gastric  fistula  is  made,  fluids  may  be  given  very  soon 
after  operation.  Several  days  should  be  taken  in  returning  to  semi- 
solids, and  two  or  three  weeks  to  solids,  if  they  are  masticated  by  the 
patient  before  introduction. 

Diet  After  Operation  Upon  the  Intestine. — ^As  examples  of  the 
general  principles  to  be  followed  in  these  cases  may  be  cited  the  direc- 
tions of  Deaver  and  of  Kelly  in  their  recent  works  on  appendicitis.  The 
former  says:  ''No  nourishment  should  be  given  by  the  mouth  until  the 
lapse  of  at  least  twenty-four  hours  after  the  operation.  If  at  the  ex- 
piration of  this  time  the  stomach  has  for  some  hours  showed  no  evidence 
of  irritability,  albumin-water,  one  of  the  commercial  preparations  of 
beef,  or  a  meat  broth  prepared  by  the  nurse,  or  milk,  peptonized  by  the 
cold  process  and  the  peptonization  not  carried  so  far  as  to  render  the 
milk  bitter,  in  doses  of  a  teaspoonful  (or  less)  may  be  given  if  the  stomach 
remains  tolerant.  Milk  with  lime-water  may  be  used  in  place  of  the 
peptonized  milk,  and  may  be  cautiously  given  every  hour  or  two.  A 
dram  or  so  of  whisky  may.  also  be  given  if  required.  If  the  stomach 
continues  retentive,  larger  quantities  of  milk  may  soon  be  given — i  to 
2  ounces  every  two  hours — and  the  quantity  increased  or  decreased 
according  to  circumstances,  and  the  intervals  lengthened  as  convales- 
cence progresses.  In  addition  to  milk,  chicken  broth,  bouillon,  liquid 
ibeef  peptonoids,  beef  peptones,  dry  champagne,  etc.,  may  be  adminis- 
tered. If  vomiting  should  return,  absolute  abstinence  from  food  and. 
liquids,  for  a  time  at  least,  will  again  become  necessary."     Kelly  states 


POSTOPKRATIVI';    DIKTKTICS.  453 

that  "all  nourishment  should  be  susjjended  after  the  ofjeratif^n  until  the 
stomach  is  settled.  The  first  focKJ  given  should  be  egg-albumen,  j>re- 
pared  by  beating  the  whites  of  4  eggs  to  a  froth  and  allowing  it  io  stand 
in  a  cool  place  for  an  hour  or  more,  when  the  lif|uid  (about  50  c.t.j  tan  be 
drained  off,  leaving  the  frothy  part  behind.  It  is  best  to  give  a  teaspoon- 
ful  at  a  time  mixed  in  2  or  3  tablespoonfuls  of  cold  water  with  a  little 
sugar  and  5  or  10  drops  of  lemon-juice.  It  may  also  be  given  in  ginger 
ale,  in  orange-juice,  or  in  sherry  wine.  About  the  third  or  fourth  day 
soft  food  may  be  given,  and  after  the  first  week  a  stronger  diet  may  be 
gradually  resumed.  As  a  rule,  attendants  are  overanxious  to  feed 
patients,  who  can  often  stand  absolute  starvation  for  four  or  five  days 
very  well."  In  cases  of  intestinal  resection,  feeding  must  be  almost 
wholly  by  enemas  for  one  week.  During  that  time  the  desire  of  the 
patient  for  something  by  the  mouth  may  be  partially  satisfied  by  giving 
I  or  2  ounces  of  liquid  food  at  four-  or  six-hour  intervals.  At  the  end  of 
the  week  semifluid  and  later  soft  foods  may  be  given  by  the  mouth. 
Particular  care  should  be  taken  to  avoid  materials  that  leave  a  large 
residue  in  the  intestine. 

Diet  after  operations  about  the  gallbladder,  pancreas,  or 
kidney  is  in  general  that  prescribed  for  laparotomy  cases,  but,  in  addi- 
tion, certain  precautions  applicable  to  each  may  profitably  be  observed. 
When  bile  is  draining  externally  or  the  pancreatic  secretion  is  diminished, 
the  exhibition  of  fats  should  be  limited.  The  employment  of  specially 
digested  foods  is  usually  not  necessary.  When  one  or  both  kidneys 
have  been  operated  upon,  a  diet  approximating  that  found  useful  in 
cases  of  nephritis  may  be  of  service  in  relieving  stress  upon  the  weakened 
organ.  Articles  of  diet  commonly  given  in  nonoperated  affections  of 
these  organs  will  readily  suggest  themselves  to  the  surgeon. 

Diet  After  Operations  About  the  Mouth. — Many  patients  who 
have  undergone  operation  involving  the  mouth,  especially  young  children 
who  have  had  a  cleft  palate  or  harelip  repaired,  and  older  people  who 
have  had  cancer  of  the  lip,  jaw,  or  tongue  removed,  tolerate  food  very 
soon  after  recovering  from  the  anesthetic.  ]\Iilk,  preferably  sterilized 
for  a  day  or  two,  is  the  most  desirable  food,  and  usually  may  be  begun 
with  but  little  preliminary  trial  of  blander  fluids.  Beef-juice  is  advan- 
tageous in  some  cases.  The  problem  here  is  chiefly  one  of  mechanics, 
how  safely  to  get  the  food  by  the  wound.  To  most  patients  it  may  be 
given  by  a  spoon,  being  therewith  placed  far  back  on  the  tongue.  In 
some  instances  a  glass  feeding-tube  connected  with  a  funnel  holding  the 


454  POSTOPERATIVE    TREATMENT. 

food  gives  greater  satisfaction ;  a  pinchcock  must  be  arranged  to  secure 
absolute  control  of  the  fluid.  Feeding  should  for  some  days  not  be 
entrusted  to  the  patient  himself,  even  an  adult,  or  to  an  untrained  as- 
sistant; only  a.n  experienced  nurse  is  competent  properly  to  administer 
food  in  such  cases.  In  special  instances  feeding  will  have  to  be  accom- 
plished through  a  nasal  tube  or  even  by  the  rectum.  It  must  be  re- 
membered that  sutured  wounds  about  the  mouth  are  usually  under  con- 
siderable tension  and  are  inherently  liable  to  separate ;  hence  the  neces- 
sity for  extra  precautions  to  prevent  unnecessary  movement  of  the  parts. 

Diet  After  Operations  About  the  Head. — The  chief  indication 
here,  especially  if  the  brain  has  been  disturbed,  is  to  supply  a  diet  that 
is  light  and  easily  digested  and  nonirritating  in  every  way;  the  last 
point  applies  particularly  to  the  circulatory  system.  Alcohol,  except  on 
the  strongest  positive  indications,  as  in  case  of  persons  habitually  using 
it,  should  not  be  administered.  Liquid  diet  should  be  the  rule  for  several 
days  in  severe  cases,  followed  by  a  similar  period  of  soft  foods,  the 
heavier  solids  being  omitted  until  convalescence  is  well  established.  If 
the  patient  is  partially  or  entirely  unconscious,  feeding  by  nasal  or 
stomach-tube  or  even  by  nutrient  enemas  may  be  necessary. 

The  Use  of  Alcohol  After  Operations. — ^As  among  physicians 
in  treating  medical  cases,  widely  divergent  opinions  are  held  by  surgeons 
regarding  the  employment  of  alcohol  after  operation.  Not  a  few  give 
it  in  some  form,  as  wine,  whisky,  or  even  brandy,  practically  as  a  routine 
measure.  Disregarding  entirely  the  temperance  aspect  of  the  question, 
I  do  not  believe  this  general  use  is  demanded  or  even  advisable.  Well- 
nourished  persons  previously  unaccustomed  to  alcohol  do  not  require  it 
after  uncomplicated  operations.  The  rule  should  be  not  to  give  alcohol; 
to  this  exceptions  may  be  made  as  indicated.  Patients  in  profound 
shock,  those  exhausted  by  long  illness  or  even  by  acute,  rapidly  wasting 
diseases,  who  can  take  or  at  least  absorb  but  little  food  after  operation, 
may  well  be  given  the  supporting  effect  of  alcohol  as  a  temporary  expe- 
dient until  food  can  be  assimilated;  in  such  cases  the  alcohol  should  be 
discontinued  at  the  earliest  possible  moment.  In  cases  of  profuse 
suppuration,  and  especially  in  septicemia,  alcohol  is  most  valuable.  To 
persons  accustomed  to  its  use,  especially  in  large  quantities,  it  must  be 
supplied  after  operation,  the  amount  to  be  regulated  by  the  demand 
based  upon  the  previous  consumption  of  the  drug. 

Feeding  by  Nutrient  Enemas. — This  should  be  accomplished 
by  means  of  a  rectal  tube  or  large  catheter  gently  inserted  into  the  bowel 


POSTOPERATIVE   DIETETICS.  455 

as  high  as  possible — at  least  8  to  12  inches.  If  practicable,  tiie  [patient 
should  lie  on  his  side,  with  the  buttocks  slightly  elevated.  The  food  is 
introduced  through  a  funnel  or  fountain  syringe  by  gravity,  never  by 
means  of  a  piston  syringe.  The  temperature  of  the  food  should  be  from 
92°  to  94°.  The  amount  should  not  exceed  8  ounces,  and  in  many 
instances  4  or  6  will  be  better  retained.  Peptonized  milk,  milk  and 
beaten  eggs,  milk-peptone,  starch  or  sugar  and  milk,  or  other  similar 
combinations  may  be  employed.  Many  surgeons  add  a  fourth  or  half 
ounce  of  wine  or  a  small  quantity  of  whisky.  In  cases  when,  soon  after 
operation,  stimulation  rather  than  nourishment  is  desired,  enemas  of 
salt  solution  and  hot  black  coffee  are  particularly  efficacious.  If  the 
rectum  is  irritable,  a  preparation  of  opium  given  with,  or  just  preceding, 
the  enema  will  aid  in  its  retention.  Enemas  should  be  given  four,  five, 
or  six  hours  apart.  Every  twenty-four  hours,  or  even  oftener  in  some 
instances,  the  bowel  should  be  thoroughly  cleansed  by  copious  high 
injections  of  saline  solution;  in  rare  cases,  this  may  be  advisable  before 
each  nutrient  enema. 


NDEX. 


Abdomen,  preparation  of,  for  operation,  lo 
author's  summary,  i6 
Kelly's  method,   lo 
Martin's  method,  3 
Morris'  method,  15 
Senn's  method,  12 
Abdominal  section  (see  Laparoiomy),  165 
Abscess,  appendicular,  226 

multiple,  following  appen- 
dicectomy,  227 
brain,  174 

drainage  and  postoperative  treat- 
ment, 301 
kidney,  261 
liver,  197 

Rhoades'  method  of  treat- 
ment, 197 
postoperative         treatment 
and  drainage,  226 
mastoid,  drainage  after,  173 
ovarian  (see  Pyosalpinx),  239 
pelvic  general  considerations,  239 
postoperative       treatment, 
240 
psoas,   general  remarks  on  after- 
treatment,  302 
Treves'    method    of    treat- 
ment, 304 
Barker's  method  of  treat- 
ment, 305 
pulmonary  (see  Empyema). 

postoperative        treatment, 
302 
retrorectal,     postoperative     treat- 
ment, 303 
stitch,    MacDonald's    method    of 
prevention,  11 
Adhesions,  postoperative,  after    abdominal 
section,  220 
methods   of   pre- 
vention, 221 
Cargile         mem- 
brane  in,    222 
following     brain 
operations,  145 
Harris'     method 
of    prevention, 

Adjuncts  to  postoperative  treatment,  122 
Alcohol,  use  of,  after  operations,  462 
Alexander's  operation,  postoperative  treat- 
ment, 25S 


Alimentation,  postoperative — 
rectal,  1 1 1 

special  formula  for,  1 1 
subcutaneous  feeding,  114 
Amjjutations,  aseptic  cases,  closed  method 
of  treatment,  372 
cicatrix,  position  of,  364 
method    of    incision    or    flap 

formation,  362 
normal    or    ideal    operation, 

367 
periosteum,  value  in,  365 
postoperative    complications, 

•    374 

atrophy    of    muscles, 

375 
changes  in  bone,  376 
changes  in  nerves,  376 
conical  stumps,  375 
faulty  stumps,  375 
painful  stumps,  375 
postoperative    treatment    in 

general,  369 
author's     method     of 

bandaging  in  septic 

cases,  373 
removal  of  dressings, 

372 
removal    of   ligatures, 

381 
removal     of    stitches, 

373 
usual  form  of  dressing, 

.  371    . 
prosthetic  considerations,  378 
partial     amputations, 
380 
septic,  open  method  of  treat- 
ment, 373 
subperiosteal  method  (Bier), 

365 
typical  methods,  369 
Amputations,  special^ 

breast,  ■  after-treatment   in   gen- 
eral, 179 
author's  method,  1S2 
Bodine's  triangular  splint 

in,  180 
changing    of    dressings, 

etc.,  181 
dressings,     usual     form, 
181 


457 


458 


INDEX. 


Amputations,  special — 

fingers       and       thumb,      after- 
treatment,  381 
foot  and  toes,  383 

Chopart's  partial,  384 

Hey's,  384 

Lisfranc's  partial,  384 

subastragaloid,  385 
hip-joint,  Wyeth's  method,  377 

postoperative  treatment, 

377 
thigh,  closed  method  of  treating 
flaps,  373 
open    method    of    treat- 
_  ment,  373 
Anastomosis,  intestinal,  201 
Andrews'  (E.  Wyllys)  method  in  hernia,  250 
Andrews'  (Frank  T.)  suture  scissors,  96 
Anemia,  treatment  of,  2 
Anesthesia — 

accidents  following,  87 

dilatation  of  stomach,  87 
hematemesis,  42 
shock  from,  85 
blood,  effects  upon,  88 
blood  pressure  during,  81 
pallor  and  feebleness  of  pulse 

after,  74 
postoperative  effects  in  general, 

73  . 

postoperative  nausea  and  vomit- 
ing, 77 
methods  of  prevention, 
78 
postoperative  thirst,  88 
posture  of  patient  after,  74 
Antiseptic  dressings,  character  of,  30  . 
fomentation,  97 
gauzes  in  general,  30 
irrigation   after   abdominal   sec- 
tion, 16 
wound  treatment,  96 
Appendicectomy — 

Brewer's  method  of  after-treat- 
ment, 229 
cause  and  treatment,  232 
fecal  fistula  after,  231 
general      remarks      concerning 
postoperative  treatment,   266 
multiple  abscess  following,  227 
Ochsner's  method  of  after-care, 

Arndt's  treatment  of  intestinal  paresis,  46 
Arteries,  ligation  of,  301 
Artificial  limbs,   general  •  remarks  concern- 
ing, 453 
method  of  applying,  453 


Bandage,  Barton's  modified,  120 
Gibson's,  120 
Martin's  abdominal,  115 


Bandage,  Randolph's,  115 

roller,  methods  of  applying,  116 
sodium  silicate,  121 
spica,  for  hand, 

hernia,  118 
knee,  119 
shoulder,  118 
Bed,  Crosby's  invalid,  124 
fracture-bed,  122 
Moore's  chair  or  commode,  125 
Munger's,  123 
Bed-sores,  prevention  of,  67 
treatment  of,  68 
Bladder,  preparatory  treatment  for  opera- 
tion, 261 
cystitis,  postoperative,  51 
cystotomy,  perineal,  postoperative 

treatment,  269 
cystotomy,  suprapubic,  262 

special  method  of  drainage 
in,  263 
Block's  method  in  cholecystostomy,  192 
Blood,  Blaud's  pill  for,  2 

effects  of  anesthetic  upon,  88 
pressure,  apparatus  for  determining, 
82 
value  of,  8r 
Bodine's  triangular  splint,  180 
Bones,  postoperative  hemorrhage  from,  40 
Horsley's  wax  in,  40 
osteomyelitis,  chronic,  411 
tubercular  disease  of,  314 
Brain,  preparation  for  cerebral  operations 
(Keen),  14 
hernia  of,  143 

surgery,  Harris'  method  of  prevent- 
ing adhesions  in,  145 
Breast,  amputation  of,  179 

methods  of  bandaging  after,  179 
author's,  182 
Bodine's,  189 
Brewer  on  appendicectomy,  229 

on  bandaging,  114 
Bronchitis,  postoperative  (see  Pneumonia), 

47 
Bubo,  postoperative  treatment,  306 
Hayden's  method,  307 
Krulle's  method,  306 


Calcium  chlorid,  use  of,  in  jaundice,  57 
Carbolic  acid,  gangrene  caused  by,  50 
Cargile  membrane — 

use  of,  in  skin-grafting,  138 
in  brain  surgery,    145 
to  prevent  postoperative 
intestinal      adhesions, 
220 
Castration,  remarks  concerning,  294 

postoperative  treatment,  297 
venous  hemorrhage  after,  295 
Cerebral    operations    (see    Operations    on 
Brain),  143 


INDEX. 


459 


Cervix  uteri,  prc'ij.iratioii  for  (jpcralioii,  9 
operations   for   laceration    of, 
258 
after-care,    removal   of 
sutures,  etc.,  259 
Christie's  (Robert  J.,  Jr.)  methofl  of  drain- 
age in  empyema,  176 
Cholecystotomy,  general    consideration    of, 
191 
Block's  operation,  192 
Morrison's    method     of 
drainage  in,  192 
Cholecystcnterostomy,  Murphy's  button  in, 

.^93 
Circumcision,  Cheyne's    method    of    after- 
care, 298 
method  of  Branford  Lewis, 
298 
Cleft  palate,  after-treatment  in  general,  153 
complications   follow^ing   ope- 
rations, 154 
failure  of  union,  causes 
and     treatment     of, 

155 
postoperative      hemor- 
rhage, treatment  of, 

secondary  operation  in,  155 
Treves'  method  of  after-treat- 
ment, 156 
Club-foot,  after-treatment  in  general,  414 
method  of  bandaging  after  ope- 
ration, 413 
methodical  manual  correction  of, 

417 
method     of    application, 
416 
talipes  calcaneus,  418 
talipes  varus  or  equinovarus,  413 
Taylor's  retention  brace,  415 
transplantation  of  tendo  Achil- 
lis,  419 
Collapse,      postoperative      (see      Surgical 

Shock),  79 
Colostomy,  general  remarks,  204 

after-treatment  in  general,  205 
for  acute  intestinal  obstruction, 

208 
Martin's  method  of  rapid,  208 
Treves'  method  in,  206 
Compound  fractures^ 

after-treatment  in  septic  cases, 

336. 
complications  during  repair  of, 

349    . 
ankylosis  of  joints,    354 
atrophy  of  muscles,  353 
delirium,  351 

treatment  of,  352 
edema,  350 
fat  embolism,  352 
gangrene  of  limb,  352 
necrosis  of  bone  in,  355 


C<jm[)ound  fractures — • 

complications  during  nrjnunion 
of  bones,  355 
paralysis,  354 
SL-jjtic  infection,  343 
surgical  emphysema,  350 
thrombosis,  353 
irrigation  in,  337 
irrigation,    continuous    method 

of.  337 
modern  treatment  of  Nicholas 

Senn,  333 
special,  arm  or  forearm,  dress- 
ing anfl  postoperative 
treatment,  343 
leg.      Buck's     extension 

apparatus  in,  341 
skull,  comminuted  frac- 
ture,        postoperative 
treatment,  339 
thigh,  341 

after-treatment  in 

general,  345 
ambulatory  splint 

in,  346 
in  childhood,  349 
Cook's  method  of  drainage  in  surgery  of 

gallbladder,  196 
Cystitis,    postoperative,    cause    and    treat- 
ment, 51 
Cystotomy,  perineal  method,  296 

drainage  in  and  postoperative 

treatment,  296 
suprapubic,     general    remarks 
on,  262 
Stephenson's    drainage- 
tube  for,  266 
Treves'  after-treatment, 
265 


Da  Costa  (J.  Chalmers)    on  treatment  of 

infected  wounds,  100 
Delirium,  postoperative,  causes  of  and  treat- 
ment, 56 
from  absorption  of 
iodoform,  57 
Depilatory,  author's  formula  for,  16 

use  of,  by  Robert  ^Morris,  15 
Diarrhea,  postoperative,  causes  of  and  treat- 
ment, 36 
Dietetics,  postoperative- 
general  rules  regarding  diet,  457 
diet    for    laparotomy    patients, 

459 
Kelly's  method,  233 
diet  after  operation  on  gall-blad- 
der, 461 
head,  462 
intestines,  460 
mouth,  461 
stomach,  460 


460 


INDEX. 


Drainage,  general  consideration  of,  29 
ordinary  wounds,  29 
material  used  in,  242 

capillary    drainage,    how 

and  when  used,  242 
combined     tubular     and 

"capillary,  244 
Mikulicz  iodoform,  243 
Morris  wick,  243 
tubular,  glass,  rubber,  etc. 
242 
ordinary  wounds,  29 
remarks  on,  by  Joseph  Price,  16 
by  Nicholas  Senn,  242 
Dressings,  antiseptic  gauze,  31 

essentials  requisite  for  good,  30 
for  amputation  of  leg  or  thigh,  373 
Dwight    (E.    W.)    method    of    abdominal 
flushing  in  peritonitis,  65 


Empyema  (or  Pleurotomy) — 

Christie's   method   of  drainage 

in,  176 
Cleaningof  lung  cavity,  Schede's 

method,  175 
dangers  attending  irrigation  of 

cavity,  177 
Hutton's  method  of  drainage  in, 

176 
method    of    securing    mobility 

after,  175 
postoperative  treatment  in  gen- 
eral, 175 
removal  of  drainage,  179 
Senn's  method  of  drainage  in, 
176 
Enemata,  nutrient,  462 

Ochsner's   method  of  ad- 
ministration, 113 
special  formula  for,  112 
purgative,  144 

special  formula  for,  145 
Enterostomy,  postoperative — 
diet  following,  210 
indications  for,  210 
Witzel's  method  of,  210 
Epithelioma,  ^-ray  treatment  of,  433 
Erysipelas,  general  symptoms  of,  59 
general  treatment  of,  60 
Henry's  treatment  with  carbolic 

acid,  60 
Kraske's   method   of   scarifica- 
tion in,  60 
local  treatment,  60 
phlegmonous  types  of,  61 
remarks  on  transmission  of,  58 
serum  in,  antistreptococcic,  60 
special  drainage  and  treatment 
of,  61 
Esophagotomy,  Davis  apparatus  for,  171 
method    of    feeding    after, 
171 


Esophagotomy,  open  treatment  of  incision, 
172 
postoperative  treatment  in 
general,  171 
Excisions  of  joints — 

ankle-joint,  postoperative  treat- 
ment of,  402 
elbow-joint,  postoperative  treat- 
ment, 392 
prevention    of    ankylosis 
after,  393 
general  remarks  on,  389 
knee-joint,  after-treatment,  398 
Cheyne's method  of  after- 
treatment,  401 
Gant's  splint  in,  399 
shoulder-joint,    after-treatment, 
390 
Treves'  method  of  treat- 
ment, 391 
subperiosteal  method  of  excision, 
advantages  claimed  for, 
.403 
disadvantages  of,  404 
results  of  method,  403 
summary  of  postoperative  treat- 
ment, 404 

Fever,  postoperative — 
causes  of,  34 
treatment  of,  35 
Field  of  operation  (see  Preparation  of  Pa- 
tients), 7 
Fingers,  amputation  of,  381 
Fistula,  postoperative — 

biliary,  causes  and  treatment  of, 

197 
fecal,  following  appendicectomy, 
231 
method  of  treatment,  232 
following  intestinal  operations, 

211 
in  ano,  postoperative  treatment, 
open  method,  286 
elastic   ligature   rdethod, 

288 
method  of  Gant,  287 
Forceps,  removal  of,  after  vaginal  hysterec- 
tomy, 236 
Fowler's  (George  R.)  position  after  appen- 
'dicectomy,  75 
in  peritonitis,  62 
Fractures,     compound     (vide     Compound 
Fractures),  333 

Gallbladder  operations — 

Cook's  method  of  drainage  in, 

196 
Kehr's  method  of  drainage  in, 

194. 
Morrison's  method  of  drainage 

in,  191 


INDEX. 


461 


Gallbladckr  oijci-alions— 

postojjeralivc  treatment  in  f^en- 
eral,  196 
Gangrene,  following  oiieralions  on  extremi- 
ties, 49 
from  carbolic  acifl,  50 
postoperative,  from  thrombosis, 

5° 
Gant's  (S.  G.)  treatment  of  fistula  in  ano, 

287 
Gasserian  ganglion — 

after-care  and  treatment,  307 
excision  of,  307 
prevention    of    postoperative 
shock  in,  309 
Gastroenterostomy,    after-care    and    treat- 
ment, 202 
Gastro-intestinal  canal,  operations  on,  222 
Gastrostomy,  feeding  after,  201 

method  of  after-treatment,  200 
Gastrotomy,  general  remarks  on,  200 
Goiter  (vide  Thyroid  Gland),  172 
Granulations,  healing  of  wound  by,  131 

Outen's  method  of  stimulation, 
132 


Hare   (Hobart   Amory)   on  bandaging  in 

postoperative  work,  115 
Hare-lip,  after-treatment  in  general,  159 

Lister's  method  of  treatment,  159 
care  of  infants  after  opera- 
tion, 159 
feeding  after,  159 
Harris  (M.  L.)  on  prevention  of  adhesions 

in  brain  surgery,  145 
Hayden's  method  of  treating  bubo,  307 
Healing  of  wounds,  131 
Htemaemesis,  24 

treatment  of,  43 
Hemophilia,  40 
Hemorrhage,  after  operations  on  tongue, 

41 
cause  and  treatment  of,  40 
from  bones,  40 
Horsley's  wax  in,  40 
in  jaundiced  patients,  57 
treatment  for,  57 
Ruspini's   styptic   for, 
58 
in  nasal  operations,  41 

method  of  controlling, 

41 
postoperative,  39 
secondary,  144 
Hemorrhoids,  after-treatment    in    general, 
280 
clamp  and  cauter}'  method, 
280 
general  remarks  con- 
cerning, 279 
complications  following  ope- 
rations, 282 


Hemorrhoifls,  (rushing  method,  282 

absrcss    and     fistula, 

282 
hemorrhage,  282 
ulceration,  283 
ligature  method,  279 

postoperative      treat- 
ment, 279 
Henry  (F.  P.)  on  carbolic  acid  in  erysipelas, 

60 
Hepatic    ducts    (vide    Gallbladder    Opera- 
tions), 194 
Hernia,  complications  following  operation, 
247 
general     postoperative    treatment, 

245 
method  of  bandaging  after  opera- 
tion, 245 
postoperative,  248 

after-treatment  of,  144 
causes  of,  249 
radical  cure  of,  250 
umbilical,  Mayo's  after-treatment, 

ventral,  following  appendicectomy, 
postoperative  treatment  of,  231 
Hip,  amputation  of,  377 

postoperative  treatment  of,  397 
Horsley's  aseptic  wax  in  hemorrhage  from 

bones,  40 
Hutchinson's  (Jonathan,  Jr.),  treatment  of 

wounds,  99 
Hydrocele,  open  method  of  treatment  of, 

287 
Hypodermatoclysis — 

indications  for  use  of,  107 
intravenous,  109 

Halsted's     formula     for 
solution,   107 
"  Kellev's    apparatus    for, 

108 
Lock's  formula  for,  107 
manner    of    administration    of, 

108 
temperature  of  solution  in,  no 
Hypospadias  (or  ectopia   vesicae),  general 
considerations,  311 
postoperative  treatment,    312 
Hysterectomy,  vaginal,  abdominal  method 
(see  Laparotomy),  215 
clamp  and  forceps  method, 

255 

after-treatment,  255 
removal  of  forceps,  256 
suture  method,  256 

after-treatment,  256 


Icterus,  calcium  chlorid  in,  57 

Kocher's  method  in,  192 
operations    on    patients    afflicted 

with,  192 
postoperative,  57 


462 


INDEX. 


Icterus,  preliminary  treatment  of  patients 

afflicted  with,  192 
Ileus,  postoperative,  43 

prevention  of,  44 
treatment  of,  44 

Arndt's  method, 

'     .  46 

Infection,  postoperative — 

character  of,  37 
general  consideration  of, 

36 
symptoms  of,  37 
treatment  of,  38 
of  wounds,  antiseptic  irrigation 

of,  337 
Da    Costa's    method    of 

treatment  of,  100 
open    method    of    treat- 
ment of,  369 
Pryor's  method  of  treat- 
ment of,   after  plastic 
operations,  99 
Injections  (see  Enemata). 
Insanity,  postoperative,  causes  and   treat- 
ment of,  57 
clinical  history  of,  56 
Intestines — 

obstruction  of,  acute,    208 
colostomy  for,  208 
enterostomy  in,  210 
feeding  after,  209 
fistula  following,  211 
.  ■  symptoms   of   shock    in, 

209 
operations  in,  general,  201 

Murphy's  button  in,  202 
postoperative  adhesions,    220 
prevention  of,  221 
Intravenous  injections — 

general  remarks  on,  107 
normal  salt  solution  for,  109 
Spencer-Collins  apparatus   for, 
109 
Intubation,    as    a    postoperative    measure, 
168 
general  remarks  on,  169 
method  of  feeding  after,  171 
O'Dwyer's  instruments  for,  170 
removal  of  tube,  170 
Inunctions,  leaf  lard  in  anemia,  2 

olive  oil,  114 
Iodoform,  tuberculous  joints,  318 
Irrigation,  antiseptic,  337 
continuous,  337 
in  .septic  wounds,  334 
thermal,  338 


Jaundice,  postoperative — 
causes  of,  57 
treatment  of,  57 

Mayo  Robson's  method 
of,  57 


Jaundice,  postoperative    capillary   oozing, 

58 
Jaw,  resection  of  lower,  148 
resection  of  upper,  147   • 
after-treatment,  149 
Jerome  (J.  N.)  on  rectal  alimentation,  in 
Joints,  resection  of,  394 
elbow,  392 

hip,  395 
knee,  400 
shoulder,  390 
vnrist,  394 
tuberculosis  of,  treatment  of,  314 

Keen's  preparation  of  patient  for  cerebral 
operations,  14 
method  of  trephining,  143 
Kehr's  drainage  of  gallbladder,  194 
Kelley  (Howard  G.)— 

apparatus  for  hypodermatocly- 

sis,  108 
on   postoperative   treatment   of 

ovariotomy,  231 
on    preparation   of   patient   for 
laparotomy,  9 
Kidneys,  abscess  of,  261 

after-treatment  in  general, 

261 
in  septic  cases,  260 
nephrectomy,  260 
nephrorrhaphy,  260 
nephrotomy,  259 
Knee,  excision  of,  398 

after-treatment  of,  401 
Kocher  (Theodor)  on  amputations,  363 
on  excision  of  joints,  389 
on   postoperative   treatment   of 

granulating  wounds,  131 
operation  for  excision  of  tongue, 
152 
method     of     after-treat- 
ment, 153 
Kraske's  method  of  extirpation  of  rectum, 
284 
scarification  in  erysipelas,  60 

Laceration  of  cervix  uteri,  postoperative 

treatment,  259 
Laminectomy,  after-treatment    in    general, 

309 
closure  of  wound,  309 
posture  of  patient,  309 
Thorburn's  method  in,  309 
Laparotomy,  general  considerations,  215 

author's  method  of  closing  ab- 
dominal wound,  21 
drainage  in  septic  cases,  217 
dry  method  of  treatment,  2 1 
Gruzdeff's  method  of  abdom- 
inal flushing,  215 
Kocher's   method    for   septic 
conditions,  217 


INDEX. 


4^^3 


Laparotomy,  Mcliurncy's  mctliod  in  septic 
cases,  219 
method  of  Franklin  H.  Mar- 
tin, 217 
position  of  incision,  218 
postoperative  treatment,  Kel- 
ly's method,  231 
Price    (Joseph)    on   drainage 

after,  17 
Treves'  method  of  after-treat- 
ment of,  222 
Laryngotomy,  165 

after-treatment    in    general, 

166 
method  of  feeding  after,  168 
Ligatures,  retention  of,  after  amputations, 

381 
Lister  (Lord),   postoperative  treatment  of 

hare-lip,  159 
Litholapxy,  postoperative  treatment  in  gen- 
eral, 267 
Keegan's  method,  267 
Thompson's  (Sir  Henry)  meth- 
od of  after-treatment,  268 
Lithotomy,  perineal  method,  269 

drainage  after,  270 
suprapubic  method,  262 

complications  following, 
271 
Liver,  general  remarks,  191 
abscess  of,  197 

Rhoade's  method  and  after- 
treatment  of,  198 
gallbladder,  postoperative  treatment 
of,  194 
Lungs,  empyema  (or  pleurotomy),  drainage 
and  postoperative  treatment,  175 
postoperative  pneumonia,  47 


Mania,  postoperative,  56 
Many-tailed  bandage,  121 
Martin  (Franklin  H.) 

after-treatment   of   laparotomy, 

217 
fixed  dressings  after  laparotomy, 

217 
on  perineorrhaphy,  271 
preparation  of  patient,  3 
rapid  colostomy  for  acute  ob- 
struction, 208 
Massage,  medico-mechanical  apparatus  for, 

126 
Mastoid  bone — 

abscess  of,  173 

complications    following 

operation,  174 
drainage  of,  174  , 

open    method    of    treat- 
ment, 173 
Barker's    point    in    trephining, 

.^75 
Maxilla,  inferior,  excision  of,  148 


Maxilla,  inferior,  'JVcves'  metliod  of  after- 
treatment,  X49 
superior,  excision  of,  147 

postoperative       treatment, 

147 
Mayo  brothers  on  modification    of  Maun- 
sell's   method   of  extirpation 
of  rectum,  285 
on  prcfjaration  of  patients  for 

stomach  ojjerations,  8 
remarks  on  gastroenterostomy, 
187 
Mayo  Robson  on  calcium  chlorid  in  jaun- 
dice, 57 
McBurney's  (Charles)  laparotomy  for  sep- 
tic conditions,  219 
Meteorism,  postoperative,  216 
causes  of,  225 
purgative  enema  for,  236 
rectal  tube  in,  224 
Mikulicz  drain,  243 
Morphin,    postoperative     indications     for, 

90 
Morris  (Robt.  T.),  depilatory,      preference 
for,  15 
on    capillary   drainage, 

243 
preparation  of  patients 
for  operation,  15 
Morrison  method  of  drainage  in  cholecystot- 

omy,  192 
Mouth,    sterilization  of,   for  operation,  8 

Miller's  formula  for,  8 
Mucous  surfaces,  disinfection  of,  13 
Murphy  (J.  B.) 

on  anastomosis,  intestinal,  202 
indications    for    use    of 

button  in,  202 
length  of  time  button  is 

retained,  203 
postoperative  treatment, 
.   203      _ 
on   vaginal  extirpation   of  rec- 
tum, 284 
Muscular  contractions  or  spasm  following- 

amputations,  371 
Myxedema  following  operation  on  thyroid 
gland,  173 


Nausea  and  vomiting  following  anesthesia^ 

77 
methods  of  prevention  and  treat- 
ment, 78 
Neck,  operations  on,  165 

posture   of   patient   after  operation, 

166 
tracheotomy,  laryngotomy,  etc.,  165 
Nephrectomy,   after-treatment   in   general,. 

261 
Nephrotomy,  general  remarks,  259 
Nerves,  importance  of  removal  of,  in  am- 
putation, 363 


464 


INDEX. 


Neurasthenia,  postoperative — - 
diagnosis  of,  55 
illustrative  case  of,  53 
nature  and  duration  of,  54 
symptoms  of,  52 
treatment  of,  55 
Nichols  (E.  H.)  on  treatment  of  chronic 

osteomyelitis,  409 
Nose,  subcutaneous  injections   of  parafi&n 
for  flat  nose,  159 
Eckstein's  method,  160 

postoperative  effects,  160 
Gersuny's  paraffin  ointment,  159 
treatment  of  postoperative  infection, 
161 
Nutrient   enemata   (vide   Rectal  Alimenta- 
tion), III 


Obstruction,  intestinal,  general  remarks, 
208 
rapid  colostomy  for,  208 
Senn  on  after-treatment,  209 
use  of  Murphy's  button  in, 
201 
Ochsner  (A.  J.) 

on   preparation   of   patient   for 

operation,  15 
on  treatment  of  appendicitis,  229 
method  of  rectal  feeding, 

229 
restriction  of  diet  in,  229 
on     treatment     of     tubercular 

joints,  318 
remarks  on  gastroenterostomy, 
.     .       ^87 
Olive  oil,  inunctions  of,  for  anemia,  199 
subcutaneous  injections  of,  144 
Osteomyelitis,  chronic,  Nichol's  method  of 
treatment,  409 
postoperative  treatment,  411 
Osteotomy,  for  curvature  of  tibia  and  fibula, 
420 
for  genu  valgum,  421 
after-treatment,  421 
Outten  (W.  B.)  on   healing   of   granulated 
surfaces,  131 
after-care  and  treat- 
ment, 233 
goldbeater's  skin  in, 
132 
Ovariotomy,  Howard    Kelly's    method    of 
after-treatment,  231 
care  of  bowels  in,  236 
dietetics  in,  233 
dressing  of  abdominal 

wound,  238 
removal  of  sutures,  238 
special  diet-lists,  234 
toilet  of  patient,  232 
meteorism   following,    causes, 
225 
treatment,  236 


Ovariotomy,    postoperative    complications, 

irritability  of  bladder 

after,  235 

temperature,   elevation 

of,  237 

remarks  on  convalescence,  238 


Pain,  after  amputations,  90 
after  laparotomy,  90 
indications  for  the  use  of  morphin, 
89 
Palate,  cleft,  Cheyne's    method    of    after- 
treatment,  153 
complications   following   ope- 
ration, 154 
causes  and  treatment, 

failure  of  union,  154 
hemorrhage,  154 
shock,  153 
results  of  operation,  :^7 
Treves'  method  of  after-treat- 
ment, 156 
Pallor,  postoperative,  significance  of,  74 

treatment  of,  74 
Paraffin,  subcutaneous  injection  of,  in  flat 
nose,  159 
postoperative  treatment,  160 
Paresis,  intestinal — 

Arndt's   method   of   treatment, 

46 
pseudo-ileus,  postoperative,  43 
illustrative  case  of,  44 
symptoms  of,  44 
treatment  in  general,  45 
Wiggin's  method  of  treatment, 
46 
Patella,  fracture  of,  356 

expectant  method  of  treatment,  357 
postoperative  treatment,  358 
restoration  of  function,  359 
Pelvic  abscess,  method  of  drainage,  240 

postoperative  treatment,  241 
Perineal  lithotomy,  269 
Perineorrhaphy,  Martin's  technic,  270 

postoperative  treatment, 
271 
Peritonitis,  postoperative — • 

antiseptic  irrigation  in,  64 
author's  summary  of  treatment 

of,  64 
choice  of  incision  for,  63 
cocain     anesthesia    in    serious 

cases  of,  62 
Dwight's  method  of  flushing  in, 

.    65 

importance  of  lavage  in,  62 

open  method  of  treatment  with 

continuous  irrigation,  64 
posture  of  patient  in,  62 
toilet  of  peritoneal  cavity  in,  63 
topical  applications  in,  61 


INDEX. 


465 


Peritonitis,  variance  of  medical  treatment, 

61 
Pirogoff  or  Symc  on — 

amputation  at  knee,  441 

atrophy  of  stump,  443 

general    remarks    on    artificial 
limbs,  444 

point  of  election,  440 

position  of  cicatrix,  442 

postoperative  condition  of  bone, 
442 

postoperative       condition       of 
nerves,  442 

redundant  tissue,  442 

tibiotarsal  amputation,  439 
Pneumonia,  postoperative,  47 
Postanesthetic  complications — 

acute  dilatation  of  stomach,  87 

anesthetic  toxic  effects,  85 

nausea  and  vomiting,  77 

pain,  89 

pseudo-ileus,  43 

thirst,  89 
Postoperative  complications — 

diarrhea,  35 

hematemesis,  42 

hemorrhage,  39 

ileus  or  paresis,  43 

infection,  36 

insanity,  56 

jaundice,  57 

neurasthenia,  52 

pneumonia,  47 

surgical  shock,  79 

thrombosis,  49 
Posture  of  patient,  after  anesthesia,  import- 
ance of,  74 
after     appendicectomy, 

75 

after  stomacli  opera- 
tions, 202 

after  neck  operations, 
165 

after  rectal  operations, 

.    75  . 

in  peritonitis,  62 

Preparation  of  field  of  operation — 

abdominal  operations,  3,  4,  9,  11 

bladder  and  kidneys,  9 

cerebral,  Keen's  method,  14 

cervix  and  uterus,  9 

eye,  8 

field  in  general,  Nicholas  Senn, 

II 
general  remarks,  7 
mouth,  nose,  and  throat,  8 
skin,  8 
stomach,  8 

Preparation  of  patients  for  operation — 
author's  summary,  16 
general  remarks,  i 
method  of  Howard  Kelly,  9 
method  of  Franklin  H.  Martin,  3 

31 


rrcp.iration  of  patients  for  oijcralion — 
method  of  Robert  Morris,  15 
method  of  A.  J.  Ochsner,  15 
method  of  Josejih  Price,  4 
method  of  Nicholas  Senn,  11 
method  of  Sir  Frederick  Treves, 
6 

Price  (Joseph)  on    postojjerativc  rirainage, 

37 
remarks  on   preparation   of 
patients  frjr  operation,  5, 
II 
solutions  for  peritoneal  cav- 
ity, 16 
use  of  sterile  gauze,   17 
Prostatectomy,     postoperative     treatment, 
292  _ 
Moynihan's  method,  292 
yjerincal  method,  293 
suprapubic  method,  293 
Prosthetic  or  compensative  appliances,  gen- 
eral remarks  on,  439 
Chopart's  mediotarsal   amputa- 
tions, 439 
Jepson  on  when  and  where  to 
amputate,  439 
Pseudo-ileus,   postoperative  (see  Intestinal 

Paresis),  43 
Pulse  as  an  indication  of  septic  absorption, 

37 
Purgative  enemata,  45 
Purgatives  after  laparotomy,  4 

Kelly's  purgative  mixture,  2 
use  of,   prior  to  operations  on 
abdomen,  2 
Pyemia,  s}Tnptoms  of,  36 

drainage  after,  240 
treatment  of,  38 
Pylorectomy,  leakage  of  gastric  juice  after, 
202 
position  of  patient  after,  202 
postoperative  treatment,  201 
Pyosalpinx,  after-treatment  in  general,  239 
drainage  after,  240 


Rectal  feeding,  alcohol  in,  112 

blood  in,  delibrinated,  112 
formula  for  enemata,  iii 
meat-extract  in,  112 
milk  in,  112 
normal   salt   solution   for, 

113 
Ochsner's  method  of  ad- 
ministration, 229 
Philadelphia  Hospital  for- 
mula for,  113 
Rectum,  abscess  of,  303 

extirpation  of,  2S3 

after-care    and    treatment, 

2S5_ 
complications       following, 
285 


466 


INDEX. 


Rectum,  extirpation  of  hemorrhoids,  post- 
operative treatment,  282 
Krask's  method,  284 
Mayo's  modification,  285 
Murphy's  vaginal  method, 

2§4 

postoperative       treatment, 
282 
Removal  of  ligatures  after  amputation,  381 
Resection  of  joints  (see  Excision),  394 
Retention  of  urine  after  laparotomy,  223 
Retroversion  of  uterus — 

abdominal  fixation  for,  postope- 
rative treatment,  165 
Alexander's  operation  for,  after- 
care of,  258 
Reverdin's  method  of  skin-grafting,  134 
Rhoades  (Thomas  L.) — ■ 

on  abscess  of  liver,  technic  of 

operation  for,  196 
after-treatment,  197 
Rochester's  method  in  pneumonia,  49 
Rontgen-rays  in    postoperative    treatment, 

425 

combined  method  of  treat- 
ment with  escharotic,  425 

dosage  and  method  of  treat- 
ment, 426 

effects  of  treatment  on  tis- 
sues, 430 

protection  of  patients,  445 

technic,  429 

tubes,  size  and  character  of, 

types  of  curable  epithelioma, 

434 
vaginal  and  rectal  tubes,  432 
Wagner's     adjustable     focus 
tube,  432 
Ruspini's  styptic  in  hemorrhage  of  liver,  58 


Salt  solution,  normal — 

after  laparotomy  in  general,  215 
hypodermatoclysis,  107 

Kelly's     apparatus     for, 
108 
in  peritonitis,  63 
intravenous,  109 

formula  of  Locke,  107 
formula    used    in    Hal- 
stead's  clinic,  107 
method  of  administration,  108 
rectal  enemata  of,  215 
Scrotum,  operations  on,  292 

edema  of  tissues  after,  294 
postoperative  treatment,  294 
Senn  (Nicholas)  on  abdominal  drainage  in 
septic  cases,  242 
amputations,  379 
drainage  in  general,  242 
empyema,  method  of  drainage 
and  after-treatment,  156 


Senn  (Nicholas),  modern  treatment  of  com- 
pound fractures,  333 
preparation  of  patients  for  ope- 
ration, 10 
treatment  of  septic  wounds,  334 
Septicemia  (see  Postoperative  Infection),  36 
Shock  surgical,  postoperative,  blood  pres- 
sure in,  82 
causes  of,  79 
character  and  extent,  79 
general  consideration  of,  79 
general  symptoms,  80 
in  operations  on  brain,  81 
methods  to  prevent,  81 
treatment  of  shock  as  result  of 
hemorrhage,  84 
psychic  disturbances,  87 
toxic  eiifects  of  anesthetic, 

85 
vaso-motor     depression, 
S3 
Silver-foil  to   prevent   adhesions   in   brain 

surgery,_  145 
Skin-grafting,  133 

after-dressings  for,  136 
after-treatment  in  general,  137 
Cargile  membrane  in,  139 
cutting     and     application     of 

grafts,  136 
essentials  for  success,  135 
Reverdin's  method  of,  134 
Thiersch's  method  of,  134 
transplantation  in  mass,  138 
preparation  of,  for  operation,  13 
Solutions  for  use  in  abdoinen,  16 
normal  salt,  215 
tap  water,  16 
Spina  bifida,  postoperative  treatment,  311 
Splints,  special — 

Agnew's  patella,  358 
ambulatory,  346 
anterior  and  posterior  leg,  398 
Bodine's  triangular,  after  breast 

amputation,  180 
Cabot's  wire,  347 
Hodgen's  suspension,  399 
Hoppe's  universal,  390 
Schaffer's  hip,  395 
Thomas  hip,  395 
Volkmann's  dorsal,   for  ankle, 
402 
Steam-tent  in  postoperative  treatment  of 

tracheotomy,  167 
Stomach,  postoperative   treatment,  gastrot- 
omy,  202 
pylorectomy,  200 
Subcutaneous  feeding,  114 
Superior  maxilla,  excision  of,  147 

after-treatment  of,  147 
Suprapubic  drainage-tube,  lithotomy,  262 
Stephenson's,  266 

Sutures,  removal  of,   in  ordinary  wounds, 
96 


INDEX. 


467 


Sutures  after  amputations,  381 

Andrews'  scissors  for,  96 
in  septic  cases,  95 
Symphysiotomy,  Ayer's  hammock  for,  313 
general    remarks   on,  312 
mechanical  aids  in    post- 
operative treatment,  312 


Talipes  (vide  Club-foot),  general  remarks 
on,  413 
calcaneovarus,  418 
mechanical  aids  in,  419 
postoperative  treatment,  418 
transplantation  of  tendo  Achillis, 

419 
varus  or  equinovarus  and  after- 
treatment,  418 
Temperament  of  patients,  importance  of, 

in  after-care,  73 
Temperature,  sudden  rise  in  infection,  36 
traumatic    or    postoperative, 

35 
Testes,  removal  of  (vide  Castration),  294 
Thigh,  amputation  of,  380 

excision  of,  394 

fracture  of,  344 
Thirst  after  anesthesia,  88 

cause  and  method  of  prevention,  89 

Semmola's  glycerin  drink  to  allay, 

458 
treatment  of,  89 
Thoracoplasty  (Schede),  179 
Thrombosis,  postoperative,  causes  of,  49 

treatment  of,  49 
Thyroid  gland,  after-treatment,  173 

important    technic    in    re- 
moval of,  172 
persistent  oozing  after,  173 
postoperative  recurrent 

hemorrhage,  172 
thyroidism  following,  173 
Tongue,  excision  of,  149 

Kocher's    method    of    after-treat- 
ment, 152 
Kocher's  method  of  dressing  after, 

152 
Sedillot-Syme  operation,  150 
Treves'  method  of  after-treatment. 

Whitehead's  operation,  149 
Trachelorrhaphy,  after-treatment,  258 
Tracheotomy,  postoperative  treatment,  165 
cleaning     and     removal     of 

tube,  166 
closure  of  incision,  167 
dietetics  and  method  of  feed- 
ing after,  168 
Jacobson's  method  of  after- 
treatment,  167 
Trephining,  postoperative  treatment,  144 
closure  of  wound,  143 
Keen's  method  in,  143 


Trej)hining,  osteoplastic  flap  (Wagner),  143 
postojjerative    .adhesions    and 

method  to  prevent,  145 
posto[)erative  hemorrhage,  144 
Treves  (Sir  Frederick) — 

after-treatment  of    cleft  palate, 

after-treatment    of     colostomy 

206 
after-treatment    of     cystotomy, 

265 
after-treatment    of    excision    of 

shoulders,  391 
after-treatment  of  wounds,  975 
on  after-treatment  of  abdominal 

section,  222 
preparation  of  patient  for  ope- 
ration, 6 
Tuberculosis  of  joints — 

Bier's  treatment  of,  318 
hip-joint  and  knee  abscess,  315 
after-treatment,  316 
Cheyne-Treves'    treat- 

ment,  315 
Phelps'  treatment  of,  317 
iodoform  glycerin  injections  in, 

3^8    ..     . 
mechanical  aids  in  postoperative 

treatment  of,  314 
postoperative  treatment  in  gen- 
eral, 315 
Ochsner's  rules  for,  319 
rest  cure  in,  134 
Thomas  brace  in,  324 
traction  and  splinting  in,  322 
Whitman'smethod  of  treatment, 
320  _ 

Turck  (R.  C.  )  on  drainage  in  pelvic  ab- 
scess, 240 
after-treatment,  241 
Tympanites,  postoperative  significance  and 
treatment  of,  237 


Umbilical  hernia,  postoperative  treatment, 

251 
Urethrotomy,  general  remarks  on,  288 

clamp  and  forceps  method  of 
controlling  hemorrhage,  290 
external  method,  289 

open  wound  in,  2  89 
internal  method,  290 

after-treatment  of,  290 
irrigation  of  urethra,  2  88 
postoperative     compUcations, 
291 
extravasation  of  urine, 

291 
treatment  of,  292 
Urine,  examination  of,  prior  to  anesthesia, 
2 
retention  of,  after  abdominal  section, 
235 


468 


INDEX. 


Urine,  suppression  of,  after  abdominal  sec- 
tion, 235 

Uterus,  operations  on  (vide  Hysterectomy), 
255 

Vagina,  operations  on  {see Perineorrhaphy), 

271 
Vaginal  hysterectomy,  treatment  of,  256 
Ventral    hernia,    postoperative,    Andrew's 
method,  250 
causes  and  treatment  of,  248 
Vomiting,  postanesthetic,  77 

method  of  prevention  and  treat- 
ment, 78 
■  use  of  lavage  in,  78 

Wiggins  on  postoperative  paresis,  46 
Wounds,  general  consideration  of,  21 

dry  method  of  treatment, 

22 
facial,  loi 

irrigation  of,  during  opera- 
tions, 22 
general  remarks  on,  21 
postoperative  drainage  and 

dressing  of,  21 
superficial  aseptic,  29 
suture  of,  21 
aseptic,  postoperative  wound  su- 
ture, 21 
in  lacerated  wounds,  loi 
closure  of  abdominal  wounds,  21 
drainage,       considerations 
of,  29 


Wounds   closure  of,  dressings  for,  29 

of  postoperative  treatment 

in  general,  95-97 
relief  of  tension  in,  21 
removal  of  sutures,  96 
Sir       Frederick       Treves' 
method     of     treatment, 
,225 
granulating,  Outten's  method  of 
treatment,  131 
skin-grafting  in,  133 

Reverdin's  method, 

134 
Thiersch's  method, 

septic  or  infected,  principles  gov- 
erning   treatment 
(Da  Costa),  100 
importance    of    rest 
in,  102 
Hutchinson    (Jno.)    treat- 
ment of  infected  wounds, 

99 

Pry  or 's  treatment  of  septic 
condition  following  plas- 
tic operations,  99 

Senn  (Nicholas)  on  irriga- 
tion  of    wounds, 

337 
treatment  of  sep- 
tic wounds,  334 


X-RAY  (see  Ront gen-ray),  value  of,  in  post- 
operative treatment,  425 


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